☰ INDEX
Breast and Endocrine
Gastrointestinal Tract
General Surgery
Hepato-Pancreatico-Biliary
Miscellaneous
Pediatric Surgery
Plastic Surgery
Trauma
Urology
Vascular Surgery and Lymphatics
<div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <h2 class="text-xl font-semibold mb-4">Instructions</h2> <h4 class="text-gray-800 text-lg font-semibold mt-6 mb-4">Test Features:</h4> <ul class="space-y-3"> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Multiple choice questions with single correct answers </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Timer-based testing for realistic exam conditions </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Mark questions for review functionality </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Comprehensive results and performance analysis </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Mobile-optimized interface for learning on-the-go </li> </ul> <div class="mt-6 flex space-x-4 button-group md:flex-row flex-col"> <button class="bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="start-test">Start Test</button> </div> <div class="error-message hidden" id="error-message"></div> </div> </section> <!-- Quiz Section --> <section class="container mx-auto px-4 md:px-6 pt-4 md:pt-6 pb-1 hidden section-transition" id="quiz"> <div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <!-- Progress Bar --> <div class="w-full bg-gray-200 rounded-full h-3 mb-4"> <div class="progress-bar h-3 rounded-full" id="progress-bar" style="width: 0%"></div> </div> <!-- Question Header --> <div class="flex flex-col md:flex-row justify-between items-center mb-4"> <h2 class="text-lg font-semibold" id="question-number">Question <span>1</span> of 4</h2> <p class="text-lg font-semibold mt-2 md:mt-0" id="timer">Time Remaining: <span>00:00</span></p> </div> <!-- Question Content --> <div class="mb-6" id="question-content"> <p class="text-gray-800 mb-4" id="question-text"></p> <div class="flex flex-wrap gap-4 mb-4" id="question-images"></div> <div class="space-y-3" id="options"></div> </div> <!-- Navigation Buttons --> <div class="flex flex-col md:flex-row justify-between items-center gap-2 md:gap-4"> <div class="flex gap-2 w-full md:w-auto"> <button class="bg-[#2c5281] text-white px-4 py-3 w-full md:w-32 h-14 rounded-lg hover:bg-[#2c5281] transition" disabled="" id="previous-btn">Previous</button> <button class="bg-[#2c5281] text-white px-4 py-3 w-full md:w-32 h-14 rounded-lg hover:bg-[#2c5281] transition" id="next-btn">Next</button> </div> <div class="flex items-center gap-2"> <button class="bg-transparent text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-100 transition flex items-center gap-1" id="mark-review"> Review <svg xmlns="http://www.w3.org/2000/svg" class="h-5 w-5" viewBox="0 0 20 20" fill="currentColor"> <path d="M10 2a1 1 0 00-1 1v14l3.293-3.293a1 1 0 011.414 0L17 17V3a1 1 0 00-1-1H10z" /> </svg> </button> <button class="bg-transparent text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-100 transition flex items-center gap-1" id="nav-toggle"> Question 🧭 </button> <button class="bg-green-500 text-white px-6 py-3 w-44 h-14 rounded-lg hover:bg-green-600 transition w-full md:w-auto" id="submit-test">Submit Test</button> </div> </div> </section> <!-- Results Section --> <section class="container mx-auto px-4 md:px-6 pt-4 md:pt-6 pb-1 hidden section-transition" id="results"> <div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <h2 class="text-2xl font-semibold mb-4">Anaesthesia Machine - Results</h2> <div class="grid grid-cols-1 md:grid-cols-2 gap-4 mb-6"> <p><strong>Correct:</strong> <span id="correct-count" class="text-[#000000]">0</span></p> <p><strong>Wrong:</strong> <span id="wrong-count" class="text-[#000000]">0</span></p> <p><strong>Unanswered:</strong> <span id="unanswered-count" class="text-[#000000]-500">0</span></p> <p><strong>Marked for Review:</strong> <span id="marked-count" class="text-[#000000]">0</span></p> </div> <h3 class="text-lg font-semibold mb-4" id="result-question-number">Question <span>1</span> of 4</h3> <div class="space-y-6" id="results-content"></div> <div class="result-nav"> <button aria-label="Previous question result" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" disabled="" id="prev-result">Previous</button> <button aria-label="Toggle results navigation panel" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="results-nav-toggle">Result 🧭</button> <button aria-label="Next question result" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="next-result">Next</button> </div> <div class="mt-6 flex space-x-4 button-group md:flex-row flex-col"> <button class="bg-green-500 text-white px-6 py-2 rounded-lg hover:bg-green-600 transition" id="take-again">Take Again</button> </div> </div> </section> <!-- Exit Confirmation Modal --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 hidden" id="exit-modal" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white rounded-lg p-6 max-w-sm w-full"> <h2 class="text-xl font-semibold mb-4">Leave Test?</h2> <p class="text-gray-700 mb-4">Your progress will be lost if you leave this page. Are you sure you want to exit?</p> <div class="flex justify-end space-x-4"> <button class="bg-gray-300 text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-400 transition" id="continue-test">No, Continue</button> <button class="bg-red-500 text-white px-4 py-2 rounded-lg hover:bg-red-600 transition" id="exit-test">Yes, Exit</button> </div> </div> </div> <!-- Submit Confirmation Modal --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 hidden" id="submit-modal" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white rounded-lg p-6 max-w-sm w-full"> <h2 class="text-xl font-semibold mb-4">Confirm Submission</h2> <p class="text-gray-700 mb-2">You have attempted <span id="attempted-count">0</span> of 4 questions.</p> <p class="text-gray-700 mb-4"><span id="unattempted-count">0</span> questions are unattempted.</p> <div class="flex justify-end space-x-4"> <button class="bg-gray-300 text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-400 transition" id="cancel-submit">Cancel</button> <button class="text-white px-4 py-2 rounded-lg hover:bg-[#1a365d] transition" style="background-color: #2c5281;" id="confirm-submit">Submit Test</button> </div> </div> </div> <!-- Quiz Navigation Panel --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 z-50 nav-panel hidden overflow-y-auto" id="nav-panel" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white shadow-lg p-4 rounded-lg w-full max-w-2xl max-h-[80vh] overflow-y-auto"> <h2 class="text-lg font-semibold mb-4">Questions Navigation</h2> <div class="mb-4"> <select class="w-full p-2 border rounded-lg text-gray-700" id="nav-filter"> <option value="all">All Questions</option> <option value="answered">Answered</option> <option value="unanswered">Unanswered</option> <option value="marked">Marked for Review</option> </select> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-nav">Close</button> </div> </div> <!-- Results Navigation Panel --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 z-50 results-nav-panel hidden overflow-y-auto" id="results-nav-panel" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white shadow-lg p-4 rounded-lg w-full max-w-2xl max-h-[80vh] overflow-y-auto"> <h2 class="text-lg font-semibold mb-4">Results Navigation</h2> <div class="mb-4"> <select class="w-full p-2 border rounded-lg text-gray-700" id="results-nav-filter"> <option value="all">All Questions</option> <option value="answered">Answered</option> <option value="unanswered">Unanswered</option> <option value="marked">Marked for Review</option> </select> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="results-nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-results-nav">Close</button> </div> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="results-nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-results-nav">Close</button> </div> <!-- JavaScript Logic --> <script> // Enable debug mode for detailed logging const DEBUG_MODE = true; // Log debug messages function debugLog(message) { if (DEBUG_MODE) { console.log(`[DEBUG] ${message}`); } } // Initialize questions with error handling let questions = []; let currentResultQuestion = 0; // State for current question in results try { debugLog("Attempting to parse questions_json"); questions = [{"text": "Which out of these is not a risk factor for breast carcinoma?", "options": [{"label": "A", "text": "Alcohol", "correct": false}, {"label": "B", "text": "Early age of first live childbirth", "correct": true}, {"label": "C", "text": "Early menarche", "correct": false}, {"label": "D", "text": "Nulliparity", "correct": false}], "correct_answer": "B. Early age of first live childbirth", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Early age of first live child birth.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Alcohol. Alcohol consumption is a well-established risk factor for the development of breast cancer . The risk increases with the amount of alcohol consumed, and this association is thought to be due to alcohol's effects on estrogen and other hormonal levels, as well as its ability to damage DNA in cells.</li><li>• Option A: Alcohol.</li><li>• Alcohol consumption</li><li>• risk factor for the development of breast cancer</li><li>• Option C: Early menarche. Early onset of menstruation (menarche) is a risk factor for breast cancer . The earlier a woman begins menstruating, the longer her breast tissue is exposed to estrogen, which can promote the growth of cancer cells.</li><li>• Option C: Early menarche.</li><li>• Early onset of menstruation</li><li>• risk factor for breast cancer</li><li>• Option D: Nulliparity. Nulliparity, or never having given birth to a child , is also a recognized risk factor for breast cancer . This is thought to be due to the absence of the protective hormonal changes that occur during pregnancy.</li><li>• Option D: Nulliparity.</li><li>• never having given birth to a child</li><li>• risk factor for breast cancer</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Protective factors for carcinoma breast:</li><li>➤ Protective factors for carcinoma breast:</li><li>➤ Early age at first pregnancy Multiparity Breastfeeding Oophorectomy Exercise Tamoxifen and aromatase inhibitors</li><li>➤ Early age at first pregnancy</li><li>➤ Multiparity</li><li>➤ Breastfeeding</li><li>➤ Oophorectomy</li><li>➤ Exercise</li><li>➤ Tamoxifen and aromatase inhibitors</li><li>➤ Risk factors for breast carcinoma:</li><li>➤ Risk factors for breast carcinoma:</li><li>➤ Age: incidence increases with increasing age. Sex: more common in females. Personal history and family history of breast cancer Race, ethnicity (white women have increased risk compared to women of other races) History of radiation exposure Mammographically dense breast Genetic factors: Mutations in tumor suppressor genes BRCA 1 BRCA 2 TP53 CHEK2 Hereditary syndromes Li Fraumeni syndrome Cowden’s syndrome HNPCC syndrome Peutz - Jeghers syndrome Ataxia telangiectasia Hormonal factors (hypercarotenemia is the risk factor) Early menarche (&lt;12 years) Late gmenopause (&gt; 55 years) First full-term pregnancy &gt;35 years Nulliparity Obesity (Postmenopausal) Higher socioeconomic status, high fat diet, alcohol intake, chest wall radiation OCPills and smoking have a low risk association</li><li>➤ Age: incidence increases with increasing age.</li><li>➤ Sex: more common in females.</li><li>➤ Personal history and family history of breast cancer</li><li>➤ Race, ethnicity (white women have increased risk compared to women of other races)</li><li>➤ History of radiation exposure</li><li>➤ Mammographically dense breast</li><li>➤ Genetic factors:</li><li>➤ Mutations in tumor suppressor genes BRCA 1 BRCA 2 TP53 CHEK2</li><li>➤ Mutations in tumor suppressor genes</li><li>➤ BRCA 1 BRCA 2 TP53 CHEK2</li><li>➤ BRCA 1</li><li>➤ BRCA 2</li><li>➤ TP53</li><li>➤ CHEK2</li><li>➤ Hereditary syndromes Li Fraumeni syndrome Cowden’s syndrome HNPCC syndrome Peutz - Jeghers syndrome Ataxia telangiectasia</li><li>➤ Hereditary syndromes</li><li>➤ Li Fraumeni syndrome Cowden’s syndrome HNPCC syndrome Peutz - Jeghers syndrome Ataxia telangiectasia</li><li>➤ Li Fraumeni syndrome</li><li>➤ Cowden’s syndrome</li><li>➤ HNPCC syndrome</li><li>➤ Peutz - Jeghers syndrome</li><li>➤ Ataxia telangiectasia</li><li>➤ Hormonal factors (hypercarotenemia is the risk factor) Early menarche (&lt;12 years) Late gmenopause (&gt; 55 years) First full-term pregnancy &gt;35 years Nulliparity Obesity (Postmenopausal) Higher socioeconomic status, high fat diet, alcohol intake, chest wall radiation</li><li>➤ Hormonal factors (hypercarotenemia is the risk factor)</li><li>➤ Early menarche (&lt;12 years) Late gmenopause (&gt; 55 years) First full-term pregnancy &gt;35 years Nulliparity Obesity (Postmenopausal) Higher socioeconomic status, high fat diet, alcohol intake, chest wall radiation</li><li>➤ Early menarche (&lt;12 years)</li><li>➤ Late gmenopause (&gt; 55 years)</li><li>➤ First full-term pregnancy &gt;35 years</li><li>➤ Nulliparity</li><li>➤ Obesity (Postmenopausal)</li><li>➤ Higher socioeconomic status, high fat diet, alcohol intake, chest wall radiation</li><li>➤ OCPills and smoking have a low risk association</li><li>➤ OCPills and smoking have a low risk association</li><li>➤ Ref : Bailey &amp; love’s short practice of surgery -28 th edition page no 931, table 58.3</li><li>➤ Ref</li><li>➤ : Bailey &amp; love’s short practice of surgery -28 th edition page no 931, table 58.3</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is not a pre malignant lesion associated with breast cancer?", "options": [{"label": "A", "text": "Apocrine metaplasia", "correct": true}, {"label": "B", "text": "Florid hyperplasia", "correct": false}, {"label": "C", "text": "Atypical hyperplasia", "correct": false}, {"label": "D", "text": "LCIS", "correct": false}], "correct_answer": "A. Apocrine metaplasia", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-171352.png"], "explanation": "<p><strong>Ans. A) Apocrine metaplasia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Florid Hyperplasia Florid hyperplasia, also known as usual ductal hyperplasia, is an overgrowth of the cells lining the ducts of the breast tissue . While it is not in itself considered premalignant, there is a slight increase in the risk of developing breast cancer compared to the general population, particularly when the hyperplasia is moderate to florid.</li><li>• Option B: Florid Hyperplasia</li><li>• usual ductal hyperplasia,</li><li>• overgrowth of the cells lining the ducts of the breast tissue</li><li>• Option C: Atypical Hyperplasia Atypical hyperplasia is a condition where there is an overgrowth of cells in the breast with some atypical (abnormal) appearance . This includes both atypical ductal hyperplasia (ADH) and atypical lobular hyperplasia (ALH). It is a recognized premalignant lesion and is associated with a higher risk of developing breast cancer — approximately four to five times the risk compared to women without these lesions.</li><li>• Option C: Atypical Hyperplasia</li><li>• where there is an overgrowth of cells in the breast with some atypical</li><li>• appearance</li><li>• Option D: LCIS Lobular Carcinoma in Situ (LCIS) is a condition in which abnormal cells are found in the lobules of the breast. This is considered a marker for an increased risk of developing breast cancer in either breast and is therefore often categorized as a premalignant lesion.</li><li>• Option D: LCIS</li><li>• abnormal cells are found in the lobules of the breast.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Apocrine metaplasia (Option A) is not a premalignant lesion associated with breast cancer ; it is a benign finding commonly seen in breast cysts and does not confer an increased risk for developing breast cancer . Conversely, conditions like florid hyperplasia, atypical hyperplasia , and LCIS are associated with a higher risk and are considered premalignant to varying degrees.</li><li>➤ Apocrine metaplasia</li><li>➤ not a premalignant lesion</li><li>➤ breast cancer</li><li>➤ benign finding commonly seen in breast cysts</li><li>➤ increased risk for developing breast cancer</li><li>➤ florid hyperplasia, atypical hyperplasia</li><li>➤ LCIS</li><li>➤ higher risk</li><li>➤ No increased risk</li><li>➤ No increased risk</li><li>➤ Adenosis, sclerosing or florid Apocrine metaplasia Cysts, macro and / or micro Duct ectasia Fibroadenoma Fibrosis Hyperplasia Mastitis (inflammation) Periductal mastitis</li><li>➤ Adenosis, sclerosing or florid</li><li>➤ Apocrine metaplasia</li><li>➤ Cysts, macro and / or micro</li><li>➤ Duct ectasia</li><li>➤ Fibroadenoma</li><li>➤ Fibrosis</li><li>➤ Hyperplasia</li><li>➤ Mastitis (inflammation)</li><li>➤ Periductal mastitis</li><li>➤ Slightly increased risk (1.5-2 times)</li><li>➤ Slightly increased risk (1.5-2 times)</li><li>➤ Hyperplasia, moderate or florid, solid, or papillary Papilloma with a fibrovascular core (relative risk =3)</li><li>➤ Hyperplasia, moderate or florid, solid, or papillary</li><li>➤ Papilloma with a fibrovascular core (relative risk =3)</li><li>➤ Moderately increased risk (5 times)</li><li>➤ Moderately increased risk (5 times)</li><li>➤ Atypical hyperplasia (ductal or lobular) (Relative risk = 4 or 5)</li><li>➤ Atypical hyperplasia (ductal or lobular) (Relative risk = 4 or 5)</li><li>➤ Insufficient data to assign a risk</li><li>➤ Insufficient data to assign a risk</li><li>➤ Solitary papilloma of lactiferous sinus Radial scar lesion</li><li>➤ Solitary papilloma of lactiferous sinus</li><li>➤ Radial scar lesion</li><li>➤ Ref : Bailey &amp; love’s short practice of surgery -27 th edition page no 871</li><li>➤ Ref</li><li>➤ : Bailey &amp; love’s short practice of surgery -27 th edition page no 871</li><li>➤ 28 th Ed. Table 58.3</li><li>➤ 28 th Ed. Table 58.3</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following statements about BRCA genes is incorrect?", "options": [{"label": "A", "text": "BRCA1 is associated with 50 to 85% lifetime risk of Ca Breast.", "correct": false}, {"label": "B", "text": "BRCA2 is located in chromosome 13.", "correct": false}, {"label": "C", "text": "BRCA1 is mostly associated with triple receptor-negative cancers.", "correct": false}, {"label": "D", "text": "BRCA1 is highly associated with male breast carcinoma.", "correct": true}], "correct_answer": "D. BRCA1 is highly associated with male breast carcinoma.", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-171906.png"], "explanation": "<p><strong>Ans. D) BRCA1 is highly associated with male breast carcinoma.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A: BRCA1 is associated with a 50 to 85% lifetime risk of Ca Breast. This statement is correct . Women with mutations in the BRCA1 gene have a significantly increased risk of developing breast cancer, with lifetime risks ranging from 50% to 85%.</li><li>• Option A: BRCA1 is associated with a 50 to 85% lifetime risk of Ca Breast.</li><li>• correct</li><li>• Option B: BRCA2 is located on chromosome 13. This statement is correct . The BRCA2 gene is indeed located on chromosome 13q.</li><li>• Option B: BRCA2 is located on chromosome 13.</li><li>• correct</li><li>• Option C: BRCA1 is mostly associated with triple receptor-negative cancers. This statement is correct . BRCA1 mutations are often associated with breast cancers that are triple-negative, meaning they lack estrogen receptors, progesterone receptors, and HER2/neu expression.</li><li>• Option C: BRCA1 is mostly associated with triple receptor-negative cancers.</li><li>• correct</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Ref : Schwartz’s principle of surgery-10 th edition page no 515</li><li>• Ref</li><li>• : Schwartz’s principle of surgery-10 th edition page no 515</li><li>• Devita-cancer principle and practice of oncology; 10 th edition page no 1109</li><li>• Devita-cancer principle and practice of oncology; 10 th edition page no 1109</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which quadrant is most commonly involved with breast carcinoma?", "options": [{"label": "A", "text": "Upper inner quadrant", "correct": false}, {"label": "B", "text": "Lower inner quadrant", "correct": false}, {"label": "C", "text": "Upper outer quadrant", "correct": true}, {"label": "D", "text": "Lower outer quadrant", "correct": false}], "correct_answer": "C. Upper outer quadrant", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Upper outer quadrant</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Upper Outer Quadrant The upper outer quadrant of the breast is the most common site for the occurrence of breast carcinoma . This quadrant contains a greater volume of breast tissue , including a significant portion of the mammary gland , making it more susceptible to the development of cancerous growths .</li><li>• Upper Outer Quadrant</li><li>• most common site for the occurrence of breast carcinoma</li><li>• quadrant</li><li>• greater volume of breast tissue</li><li>• portion of the mammary gland</li><li>• more susceptible</li><li>• development of cancerous growths</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The upper outer quadrant of the breast is the most common site for the development of breast carcinoma due to the greater volume of breast tissue present in this area (&gt;50% Terminal ductal units).</li><li>➤ upper outer quadrant of the breast</li><li>➤ common site for the development of breast carcinoma</li><li>➤ Ref : Bailey &amp; love’s short practice of surgery -28 th edition page no 932</li><li>➤ Ref</li><li>➤ : Bailey &amp; love’s short practice of surgery -28 th edition page no 932</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A woman presents with rapidly progressive breast lump with skin changes as shown. What is the likely pathology responsible for this finding?", "options": [{"label": "A", "text": "Infiltration of Cooper’s ligaments", "correct": false}, {"label": "B", "text": "Obstruction of subcutaneous lymphatics", "correct": true}, {"label": "C", "text": "Infiltration of lactiferous duct", "correct": false}, {"label": "D", "text": "Infiltration of subcutaneous veins", "correct": false}], "correct_answer": "B. Obstruction of subcutaneous lymphatics", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-172458.png"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/26/picture1.png"], "explanation": "<p><strong>Ans. B) Obstruction of subcutaneous lymphatics</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option C: Infiltration of Lactiferous Duct While the infiltration of lactiferous ducts can lead to nipple retraction or inversion , it is not the cause of Peau d'orange . Nipple retraction occurs because the ducts shorten as they are invaded by cancer cells, which pulls the nipple inward.</li><li>• Option C: Infiltration of Lactiferous Duct</li><li>• lead to nipple retraction or inversion</li><li>• not the cause of Peau d'orange</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Peau d'orange in breast carcinoma is specifically caused by the obstruction of subcutaneous lymphatics, leading to lymphatic edema and the characteristic orange peel-like texture of the skin , an indicator of advanced disease (T4b).</li><li>➤ Peau d'orange in breast carcinoma</li><li>➤ caused by the obstruction of subcutaneous lymphatics,</li><li>➤ lymphatic edema</li><li>➤ characteristic orange peel-like texture of the skin</li><li>➤ Peau D'orange is caused by cutaneous lymphatic edema due to the obstruction of subcutaneous lymphatics . It is French for “ orange skin ”.</li><li>➤ Peau D'orange</li><li>➤ cutaneous lymphatic edema</li><li>➤ obstruction of subcutaneous lymphatics</li><li>➤ orange skin</li><li>➤ Other appearances due to local invasion are as follows:</li><li>➤ Infiltration of single cooper's ligaments leads to dimpling of skin while multiple ligaments leads to puckering/wrinkling. Simple maneuvers such as stretching the arms high above the head or tensing the pectoralis muscles may accentuate asymmetries and dimpling. Infiltration of the lactiferous ducts leads to nipple retraction. Note: an inverted nipple can be simply pulled out, however a retracted nipple cannot be pulled out. Cancer-en-cuirasse: in this condition, the skin of the chest is infiltrated with carcinoma and its appearance has been compared to that of a coat. It occurs in local recurrence after mastectomy.</li><li>➤ Infiltration of single cooper's ligaments leads to dimpling of skin while multiple ligaments leads to puckering/wrinkling. Simple maneuvers such as stretching the arms high above the head or tensing the pectoralis muscles may accentuate asymmetries and dimpling.</li><li>➤ Infiltration of the lactiferous ducts leads to nipple retraction. Note: an inverted nipple can be simply pulled out, however a retracted nipple cannot be pulled out.</li><li>➤ Cancer-en-cuirasse: in this condition, the skin of the chest is infiltrated with carcinoma and its appearance has been compared to that of a coat. It occurs in local recurrence after mastectomy.</li><li>➤ Note:</li><li>➤ Note:</li><li>➤ Peau D'orange indicates skin involvement (T4b) in breast carcinoma. Dimpling of the skin and nipple retraction do not indicate skin involvement.</li><li>➤ Peau D'orange indicates skin involvement (T4b) in breast carcinoma.</li><li>➤ Peau D'orange indicates skin involvement (T4b)</li><li>➤ Dimpling of the skin and nipple retraction do not indicate skin involvement.</li><li>➤ Ref : Bailey &amp; love’s short practice of surgery -28 th edition page 932, Schwartz’s principles of surgery- 10 th edition page no 518, Sabiston textbook of surgery 20 th edition page no 849</li><li>➤ Ref</li><li>➤ : Bailey &amp; love’s short practice of surgery -28 th edition page 932, Schwartz’s principles of surgery- 10 th edition page no 518, Sabiston textbook of surgery 20 th edition page no 849</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Arrange the following types of carcinomas in the order of best to worse prognosis: Medullary carcinoma Tubular carcinoma Invasive ductal carcinoma Inflammatory carcinoma", "options": [{"label": "A", "text": "1,2,4,3", "correct": false}, {"label": "B", "text": "2,1,3,4", "correct": true}, {"label": "C", "text": "3,1,2,4", "correct": false}, {"label": "D", "text": "1,3,2,4", "correct": false}], "correct_answer": "B. 2,1,3,4", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-172941.png"], "explanation": "<p><strong>Ans. B) 2,1,3,4</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In which of the given cases is this procedure usually performed?", "options": [{"label": "A", "text": "MRM in node negative patients", "correct": false}, {"label": "B", "text": "MRM in node positive patients", "correct": false}, {"label": "C", "text": "BCT in node negative patients", "correct": true}, {"label": "D", "text": "BCT in node positive patients", "correct": false}], "correct_answer": "C. BCT in node negative patients", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/26/picture1_bjxNn3P.png"], "explanation_images": [], "explanation": "<p><strong>Ans. C) BCT in node negative patients</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A and B: MRM: Axillary lymph node dissection is usually performed as part of the surgical treatment rather than SLNB in all cases of MRM.</li><li>• Option A and B: MRM:</li><li>• Axillary lymph node dissection</li><li>• performed as part of the surgical treatment</li><li>• Option D: BCT in Node-Positive Patients In node-positive patients, BCT would include an axillary lymph node dissection to address the known nodal involvement , rather than just an SLNB, because the presence of cancer cells in the lymph nodes is already confirmed.</li><li>• Option D: BCT in Node-Positive Patients</li><li>• BCT would include an axillary lymph node dissection to address the known nodal involvement</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Sentinel lymph node biopsy is most commonly performed as part of breast-conserving therapy in patients with no clinical evidence of lymph node involvement (node-negative) to determine the presence of metastatic cancer cells in the sentinel lymph node .</li><li>➤ Sentinel lymph node biopsy</li><li>➤ breast-conserving therapy</li><li>➤ no clinical evidence of lymph node involvement</li><li>➤ presence of metastatic cancer cells</li><li>➤ sentinel lymph node</li><li>➤ Sentinel lymph node biopsy:</li><li>➤ Sentinel lymph node biopsy:</li><li>➤ First performed by Dr. Cabana for penile carcinoma Sentinel lymph node is the first draining lymph node Only done on node-negative tumors as a part of BCS/BCT. In node positive patients, BCT includes axillary lymph node clearance directly (without SLNB). In MRM, axillary clearance is done irrespective of clinical nodal status. Technique: methylene blue dye or radioisotope (technetium)-labeled albumin is injected into breast tissue (or subdermal tissue) at the site of the primary tumor or at the subareolar position. The sentinel node is identified as a blue node or as a radioactive node (using a gamma camera). The frozen section biopsy is sent to the pathologist for identification of cancer cells. If the biopsy is positive for cancer cells, then axillary dissection is simultaneously performed. The combination of blue dye and technetium-labeled colloid has been reported to improve the detection of sentinel lymph nodes. Newer techniques involve the use of a fluorescent or magnetic tracer instead of the radiolabeled dye.</li><li>➤ First performed by Dr. Cabana for penile carcinoma</li><li>➤ Sentinel lymph node is the first draining lymph node</li><li>➤ Only done on node-negative tumors as a part of BCS/BCT. In node positive patients, BCT includes axillary lymph node clearance directly (without SLNB).</li><li>➤ Only done on node-negative tumors as a part of BCS/BCT. In node positive patients, BCT includes axillary lymph node clearance directly (without SLNB).</li><li>➤ In MRM, axillary clearance is done irrespective of clinical nodal status.</li><li>➤ In MRM, axillary clearance is done irrespective of clinical nodal status.</li><li>➤ Technique: methylene blue dye or radioisotope (technetium)-labeled albumin is injected into breast tissue (or subdermal tissue) at the site of the primary tumor or at the subareolar position. The sentinel node is identified as a blue node or as a radioactive node (using a gamma camera).</li><li>➤ The frozen section biopsy is sent to the pathologist for identification of cancer cells. If the biopsy is positive for cancer cells, then axillary dissection is simultaneously performed.</li><li>➤ The combination of blue dye and technetium-labeled colloid has been reported to improve the detection of sentinel lymph nodes.</li><li>➤ Newer techniques involve the use of a fluorescent or magnetic tracer instead of the radiolabeled dye.</li><li>➤ Ref : Bailey &amp; love’s practice of surgery -28 th edition page no 936-37.</li><li>➤ Ref</li><li>➤ : Bailey &amp; love’s practice of surgery -28 th edition page no 936-37.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A woman presents with a breast tumor of size 6 x 3cm, with adherence to the pectoralis major muscle. Overlying skin shows dimpling. As her surgeon, what will you designate her T staging as?", "options": [{"label": "A", "text": "T3", "correct": true}, {"label": "B", "text": "T4a", "correct": false}, {"label": "C", "text": "T4b", "correct": false}, {"label": "D", "text": "T4c", "correct": false}], "correct_answer": "A. T3", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-173615.png", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-173816.png"], "explanation": "<p><strong>Ans. A) T3</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• The tumor is of size 6cm . Hence it is stage T3 (&gt;5cm). Fixity to pectoralis major doesn’t affect staging . Skin dimpling is not classified as T4b.</li><li>• tumor is of size 6cm</li><li>• T3 (&gt;5cm).</li><li>• Fixity to pectoralis major doesn’t affect staging</li><li>• not</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Irrelevant to the size of the tumor , if the tumor shows extension to the chest wall or skin , it is classified as T4 . However, there are two exceptions.</li><li>➤ Irrelevant to the size of the tumor</li><li>➤ tumor shows extension to the chest wall or skin</li><li>➤ T4</li><li>➤ Invasion or adherence to pectoralis muscle in the absence of chest wall involvement does not qualify as T4. Similarly, involvement of the dermis in the form of dimpling/puckering/retraction of nipple does not qualify as T4.</li><li>➤ Invasion or adherence to pectoralis muscle in the absence of chest wall involvement does not qualify as T4.</li><li>➤ Similarly, involvement of the dermis in the form of dimpling/puckering/retraction of nipple does not qualify as T4.</li><li>➤ Points to Remember</li><li>➤ Points to Remember</li><li>➤ In tumor size assessment, the greatest dimension is taken into consideration. For example, in a 6*3 cm lump, 6 cm is taken into account, and the tumor is classified as T3(&gt;5 cm). Skin involvement does not include nipple retraction and skin dimpling. Supraclavicular lymph node involvement indicates N3c. Any contralateral lymph node involvement is considered as distant metastasis. If 2 lumps are present in the same breast, staging is according to the bigger lump. If lumps are present in both breasts, separate staging is done for both the lumps.</li><li>➤ In tumor size assessment, the greatest dimension is taken into consideration. For example, in a 6*3 cm lump, 6 cm is taken into account, and the tumor is classified as T3(&gt;5 cm).</li><li>➤ Skin involvement does not include nipple retraction and skin dimpling.</li><li>➤ Supraclavicular lymph node involvement indicates N3c.</li><li>➤ Any contralateral lymph node involvement is considered as distant metastasis.</li><li>➤ If 2 lumps are present in the same breast, staging is according to the bigger lump.</li><li>➤ If lumps are present in both breasts, separate staging is done for both the lumps.</li><li>➤ TNM Staging of carcinoma breast.</li><li>➤ TNM Staging of carcinoma breast.</li><li>➤ #Chest wall includes serratus anterior, intercostal muscles, ribs. Pectoralis muscle is not a part of the chest wall.</li><li>➤ *Inflammatory breast carcinoma (stage IIIB) is characterized by the skin changes of brawny induration, erythema with a raised edge, and edema (peau d'orange) involving ≥ 1/3 rd of breast.</li><li>➤ Note: LCIS (lobular carcinoma in situ) is considered as a benign condition and not included under Tis.</li><li>➤ Note: LCIS (lobular carcinoma in situ) is considered as a benign condition and not included under Tis.</li><li>➤ Ref : Sabiston textbook of surgery 20 th edition page no 843 and 844, Schwartz’s principle of surgery -10 th edition page no 532, Journal AJCC-2017, Pg 674.</li><li>➤ Ref</li><li>➤ : Sabiston textbook of surgery 20 th edition page no 843 and 844, Schwartz’s principle of surgery -10 th edition page no 532, Journal AJCC-2017, Pg 674.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient present with a left breast lump of size 3cm x 4cm. The overlying skin has a ‘orange-like skin’ appearance. On the right side, mobile axillary nodes are palpable. On the left side, supraclavicular lymph nodes are palpable. The most appropriate tumor staging is:", "options": [{"label": "A", "text": "T2 N2a M0", "correct": false}, {"label": "B", "text": "T4b N3c M0", "correct": false}, {"label": "C", "text": "T2 N3c M1", "correct": false}, {"label": "D", "text": "T4b N3c M1", "correct": true}], "correct_answer": "D. T4b N3c M1", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) T4b N3c M1</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• In the TNM staging system for breast cancer , T refers to the size and extent of the main tumor , N describes the absence or presence and extent of regional lymph node involvement , and M indicates the absence or presence of distant metastases.</li><li>• TNM staging system for breast cancer</li><li>• T</li><li>• size and extent of the main tumor</li><li>• N</li><li>• absence or presence and extent of regional lymph node involvement</li><li>• M</li><li>• absence or presence of distant metastases.</li><li>• Tumor of any size with overlying skin involvement (Peau d'orange appearance): T4b Ipsilateral supraclavicular lymph node involvement : N3c Involvement of any contralateral lymph nodes indicates metastasis in the case of breast carcinoma: M1 Therefore, the staging is T4b N3c M1 .</li><li>• Tumor of any size with overlying skin involvement (Peau d'orange appearance): T4b</li><li>• Tumor of any size with overlying skin involvement</li><li>• Ipsilateral supraclavicular lymph node involvement : N3c</li><li>• Ipsilateral supraclavicular lymph node involvement</li><li>• Involvement of any contralateral lymph nodes indicates metastasis in the case of breast carcinoma: M1</li><li>• Involvement of any contralateral lymph nodes</li><li>• Therefore, the staging is T4b N3c M1 .</li><li>• T4b N3c M1</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the mismatch receptor profile of breast cancer:", "options": [{"label": "A", "text": "Luminal A: ER/PR +, Her 2 -, Ki67 high", "correct": true}, {"label": "B", "text": "Luminal B: ER +, Her 2 -, Ki 67 high", "correct": false}, {"label": "C", "text": "Triple negative: ER/PR -, Her 2 -, Ki 67 high", "correct": false}, {"label": "D", "text": "Her 2 enriched: ER/PR -, Her 2 +, Ki 67 high", "correct": false}], "correct_answer": "A. Luminal A: ER/PR +, Her 2 -, Ki67 high", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-174420.png"], "explanation": "<p><strong>Ans. A) Luminal A: ER/PR +, Her 2 -, Ki67 high</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Luminal B: ER +, Her 2 -, Ki 67 high. Luminal B cancers are ER-positive and tend to have a higher Ki-67 index than Luminal A , indicating a higher proliferation rate . They can be HER2 negative. This option is a correct match for the Luminal B subtype.</li><li>• Option B: Luminal B: ER +, Her 2 -, Ki 67 high.</li><li>• ER-positive and tend to have a higher Ki-67 index than Luminal A</li><li>• higher proliferation rate</li><li>• Option C: Triple Negative: ER, PR -, Her 2 -, Ki 67 high. Triple-negative breast cancers lack ER, PR, and HER2 expression. They often have a higher Ki-67 index, which is consistent with their more aggressive behavior. This option correctly describes the Triple Negative subtype.</li><li>• Option C: Triple Negative: ER, PR -, Her 2 -, Ki 67 high.</li><li>• lack ER, PR, and HER2 expression.</li><li>• Option D: Her 2 enriched: ER/PR -, Her 2 +, Ki 67 high. HER2-enriched cancers are characterized by the absence of hormone receptors (ER and PR negative) and overexpression/amplification of HER2 . They often exhibit high Ki-67 levels, which correlates with the aggressive nature of this subtype. This option correctly represents the HER2-enriched subtype.</li><li>• Option D: Her 2 enriched: ER/PR -, Her 2 +, Ki 67 high.</li><li>• characterized by the absence of hormone receptors</li><li>• overexpression/amplification of HER2</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Luminal A breast cancers are typically ER/PR positive, HER2 negative, and have a low Ki-67 index , indicating lower proliferation rates . The presence of a high Ki-67 index in this subtype, as indicated in Option A, is a mismatch.</li><li>➤ Luminal A breast cancers</li><li>➤ ER/PR positive, HER2 negative,</li><li>➤ low Ki-67 index</li><li>➤ lower proliferation rates</li><li>➤ Along with ER, PR, and Her-2, a proliferation index known as ki-67 index is also used. Ki 67 is a nuclear protein associated with cellular proliferation.</li><li>➤ Molecular classification of cancers:</li><li>➤ Molecular classification of cancers:</li><li>➤ Ref : Bailey 28 th Ed. Pg 931, Table 58.4</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 931, Table 58.4</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Given below are 4 statements regarding the lymphatic drainage of the breast. Choose the false statement:", "options": [{"label": "A", "text": "The axillary nodes receive approximately 80-85% of the drainage.", "correct": false}, {"label": "B", "text": "The lateral group is located along the axillary vein.", "correct": false}, {"label": "C", "text": "The anterior group is usually the sentinel node for CA breast", "correct": false}, {"label": "D", "text": "Lymph nodes of Rotor belong to level III", "correct": true}], "correct_answer": "D. Lymph nodes of Rotor belong to level III", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-180553.png"], "explanation": "<p><strong>Ans. D) Lymph nodes of Rotor belong to level III.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A: The axillary nodes receive approximately 80-85% of the drainage. This statement is true . The axillary lymph nodes are the primary drainage site for the lymphatics of the breast, receiving the majority of the lymphatic flow.</li><li>• Option A: The axillary nodes receive approximately 80-85% of the drainage.</li><li>• true</li><li>• Option B: The lateral group is located along the axillary vein. This statement is also true . The lateral group of axillary lymph nodes is found along the axillary vein and is often involved in the lymphatic drainage from the upper limb and breast.</li><li>• Option B: The lateral group is located along the axillary vein.</li><li>• true</li><li>• Option C: The anterior group is usually the sentinel node for CA breast. This is true . The anterior group of axillary lymph nodes, located along the lateral thoracic vessels, often contains the sentinel lymph node in cases of breast cancer, which is the first node to receive lymphatic drainage from a tumor.</li><li>• Option C: The anterior group is usually the sentinel node for CA breast.</li><li>• true</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The false statement regarding the lymphatic drainage of the breast is that Rotter's nodes belong to level III ; instead, they are part of Level II axillary nodes , situated between the pectoralis major and minor muscles.</li><li>➤ false statement regarding the lymphatic drainage of the breast is that Rotter's nodes belong to level III</li><li>➤ part of Level II axillary nodes</li><li>➤ between the pectoralis major and minor muscles.</li><li>➤ Lymph nodes are divided on the basis of their relation to the pectoralis minor , not the pectoralis major.</li><li>➤ Lymph nodes</li><li>➤ divided on the basis of their relation to the pectoralis minor</li><li>➤ Lymphatic drainage of breast:</li><li>➤ The lymphatics of breast drain predominantly into:</li><li>➤ The axillary lymph nodes (85%) Internal mammary lymph nodes Posterior intercostal/ interpectoral/Rotter’s lymph nodes</li><li>➤ The axillary lymph nodes (85%)</li><li>➤ Internal mammary lymph nodes</li><li>➤ Posterior intercostal/ interpectoral/Rotter’s lymph nodes</li><li>➤ The axillary nodes are arranged in the following groups:</li><li>➤ Level I ( lymph nodes located lateral to pectoralis minor muscle ):</li><li>➤ Level I</li><li>➤ lymph nodes located lateral to pectoralis minor muscle</li><li>➤ Lateral, along the axillary vein-drains most of upper limb Anterior (external mammary group or pectoral group), along the lateral thoracic vessels- drains most of the breast. (1 st relay station for lymph) Posterior (scapular group), along the subscapular vessels</li><li>➤ Lateral, along the axillary vein-drains most of upper limb</li><li>➤ Anterior (external mammary group or pectoral group), along the lateral thoracic vessels- drains most of the breast. (1 st relay station for lymph)</li><li>➤ Posterior (scapular group), along the subscapular vessels</li><li>➤ Level II ( lymph nodes nodes located superficial or deep to pectoralis minor muscle ):</li><li>➤ Level II</li><li>➤ lymph nodes nodes located superficial or deep to pectoralis minor muscle</li><li>➤ Central, embedded in at in the center of the axilla- receive drainage from level I groups Interpectoral (Rotter's node) - a few nodes lying between the pectoralis major and minor muscles.</li><li>➤ Central, embedded in at in the center of the axilla- receive drainage from level I groups</li><li>➤ Interpectoral (Rotter's node) - a few nodes lying between the pectoralis major and minor muscles.</li><li>➤ Interpectoral (Rotter's node)</li><li>➤ Level III ( lymph nodes located medial to pectoralis minor muscle ):</li><li>➤ Level III</li><li>➤ lymph nodes located medial to pectoralis minor muscle</li><li>➤ Apical (sub-clavicular group), which lie above the level of the pectoralis minor tendon in continuity with the lateral nodes and which receive the efferent of all the other axillary groups and drains into subclavian lymphatic trunk.</li><li>➤ Apical (sub-clavicular group), which lie above the level of the pectoralis minor tendon in continuity with the lateral nodes and which receive the efferent of all the other axillary groups and drains into subclavian lymphatic trunk.</li><li>➤ Internal mammary nodes drain the posterior one-third of the breast.</li><li>➤ Ref : Bailey and love’s short practice of surgery -28 th edition page no 915, Schwartz’s principles of surgery – 10 th edition page no 502</li><li>➤ Ref</li><li>➤ : Bailey and love’s short practice of surgery -28 th edition page no 915, Schwartz’s principles of surgery – 10 th edition page no 502</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is true about the oncotype Dx, a molecular test used for breast cancer?", "options": [{"label": "A", "text": "Used for hormone receptor -negative cancers", "correct": false}, {"label": "B", "text": "Provides risk of recurrence and chemotherapy benefit after surgery", "correct": true}, {"label": "C", "text": "Lower scores predict higher risk of recurrence", "correct": false}, {"label": "D", "text": "Used for lymph node-positive cancers", "correct": false}], "correct_answer": "B. Provides risk of recurrence and chemotherapy benefit after surgery", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-181033.png"], "explanation": "<p><strong>Ans. B) Provides risk of recurrence and chemotherapy benefit after surgery</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Used for hormone receptor-negative cancers. This statement is not true. The Oncotype DX test is specifically used for hormone receptor-positive , HER2-negative breast cancers.</li><li>• Option A. Used for hormone receptor-negative cancers.</li><li>• Oncotype DX test is specifically used for hormone receptor-positive</li><li>• Option C. Lower scores predict higher risk of recurrence. This statement is false. In the Oncotype DX assay , lower scores actually predict a lower risk of recurrence and a lesser benefit from chemotherapy.</li><li>• Option C. Lower scores predict higher risk of recurrence.</li><li>• Oncotype DX assay</li><li>• lower scores</li><li>• lower risk of recurrence</li><li>• Option D. Used for lymph node-positive cancers. The initial validation of the Oncotype DX test was for use in lymph node-negative patients . It is not generally used for cancers with high lymph node positivity.</li><li>• Option D. Used for lymph node-positive cancers.</li><li>• initial validation of the Oncotype DX test</li><li>• use in lymph node-negative patients</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Oncotype DX test is used to determine the risk of recurrence and potential chemotherapy benefit in early-stage , hormone receptor-positive , HER2-negative breast cancer , with lower scores indicating a lower risk of recurrence and a lesser benefit from chemotherapy.</li><li>➤ Oncotype DX test</li><li>➤ determine the risk of recurrence and potential chemotherapy benefit in early-stage</li><li>➤ hormone receptor-positive</li><li>➤ HER2-negative breast cancer</li><li>➤ lower scores</li><li>➤ lower risk of recurrence</li><li>➤ Oncotype Dx assay is a molecular test based on the assessment of 21 genes. It is a 21-gene recurrence score assay, in which higher recurrence scores predict increased benefit from chemotherapy. On the other hand, lower scores in this assay predict lesser benefit from chemotherapy and increased benefit from endocrine therapy. It is used for patients with lymph node-negative, ER-positive early breast cancer (Stage 1 or 2) . Newer molecular tests for breast cancer have been developed, which help in predicting the advantage of adding chemotherapy .</li><li>➤ Oncotype Dx assay is a molecular test based on the assessment of 21 genes. It is a 21-gene recurrence score assay, in which higher recurrence scores predict increased benefit from chemotherapy. On the other hand, lower scores in this assay predict lesser benefit from chemotherapy and increased benefit from endocrine therapy.</li><li>➤ It is used for patients with lymph node-negative, ER-positive early breast cancer (Stage 1 or 2) .</li><li>➤ lymph node-negative, ER-positive early breast cancer (Stage 1 or 2)</li><li>➤ Newer molecular tests for breast cancer have been developed, which help in predicting the advantage of adding chemotherapy .</li><li>➤ chemotherapy</li><li>➤ Newer molecular tests for breast cancer:</li><li>➤ Newer molecular tests for breast cancer:</li><li>➤ Oncotype Dx MammaPrint Endo Predict PAM50</li><li>➤ Oncotype Dx</li><li>➤ MammaPrint</li><li>➤ Endo Predict PAM50</li><li>➤ Using these molecular tests, a recurrence score (0-100) is calculated. If the score is low, then there is no advantage of adding chemotherapy.</li><li>➤ Using these molecular tests, a recurrence score (0-100) is calculated.</li><li>➤ If the score is low, then there is no advantage of adding chemotherapy.</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 940, American joint cancer committee 8 th edition Pg 622-623, Sabiston textbook of surgery 20 th edition page no 855.</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th Ed. Pg 940, American joint cancer committee 8 th edition Pg 622-623, Sabiston textbook of surgery 20 th edition page no 855.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "The most common site for the hematogenous spread of breast carcinoma is:", "options": [{"label": "A", "text": "Lumbar vertebrae", "correct": true}, {"label": "B", "text": "Thoracic vertebrae", "correct": false}, {"label": "C", "text": "Femur", "correct": false}, {"label": "D", "text": "Skull", "correct": false}], "correct_answer": "A. Lumbar vertebrae", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Lumbar vertebrae</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Lumbar vertebrae , followed by the femur and thoracic vertebrae , are the most common sites for hematogenous spread of carcinoma breast.</li><li>• Lumbar vertebrae</li><li>• femur and thoracic vertebrae</li><li>• most common</li><li>• sites for hematogenous spread</li><li>• carcinoma breast.</li><li>• They occur via: Breast → Posterior intercostal vein → Bateson’s plexus → Lumbar vertebrae .</li><li>• Breast → Posterior intercostal vein → Bateson’s plexus → Lumbar vertebrae</li><li>• These bone metastases are more osteolytic than osteoblastic.</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Most common sites of blood borne metastases (bone) are as follows:</li><li>• L= Lumbar vertebrae (due to Bateson’s plexus) F= Femur T= Thoracic vertebrae R= Ribs S= Skull</li><li>• L= Lumbar vertebrae (due to Bateson’s plexus)</li><li>• F= Femur</li><li>• T= Thoracic vertebrae</li><li>• R= Ribs</li><li>• S= Skull</li><li>• Metastasis to the brain occurs via: Posterior intercostal vein → Bateson’s plexus → Dural venous sinus → Leptomeninges.</li><li>• Posterior intercostal vein</li><li>• → Bateson’s plexus → Dural venous sinus → Leptomeninges.</li><li>• Note: In prostate cancer, the bone metastases are more osteoblastic than osteolytic.</li><li>• Note: In prostate cancer, the bone metastases are more osteoblastic than osteolytic.</li><li>• Ref : Bailey &amp; love’s short practice of surgery -27 th edition page no 874, 28 th Ed. Pg 932.</li><li>• Ref : Bailey &amp; love’s short practice of surgery -27 th edition page no 874, 28 th Ed. Pg 932.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient with early breast carcinoma of stage T2 N1 M0 doesn’t want to undergo mastectomy. Which of these is not a contra-indication for breast conservation in this patient?", "options": [{"label": "A", "text": "Tumor is located in multiple quadrants", "correct": false}, {"label": "B", "text": "Patient is not compliant with radiotherapy", "correct": false}, {"label": "C", "text": "Patient has ipsilateral palpable axillary lymph node", "correct": true}, {"label": "D", "text": "Patient has received prior radiotherapy on neck and chest for lymphoma", "correct": false}], "correct_answer": "C. Patient has ipsilateral palpable axillary lymph node", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Patient has ipsilateral palpable axillary lymph node</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Tumor is located in multiple quadrants: This can be a consideration against breast conservation because it may be challenging to achieve clear margins and adequate tumor removal .</li><li>• Option A.</li><li>• Tumor is located in multiple quadrants:</li><li>• consideration against breast conservation</li><li>• may be challenging to achieve clear margins</li><li>• adequate tumor removal</li><li>• Option B. Patient is not compliant with radiotherapy: Compliance with radiation therapy is crucial for the success of breast conservation . If a patient is unwilling or unable to comply with the recommended course of radiation therapy, breast conservation may not be the best option.</li><li>• Option B.</li><li>• Patient is not compliant with radiotherapy:</li><li>• Compliance with radiation therapy</li><li>• success of breast conservation</li><li>• Option D . Patient has received prior radiotherapy on neck and chest for lymphoma: Prior radiation therapy in the region may impact the ability to deliver additional radiation safely . The presence of prior radiation to the chest is contraindication to further radiation therapy.</li><li>• Option D</li><li>• Patient has received prior radiotherapy on neck and chest for lymphoma:</li><li>• Prior radiation</li><li>• therapy</li><li>• region may impact the ability to deliver additional radiation safely</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Breast conservative surgery is also known as segmental mastectomy, lumpectomy, partial mastectomy, wide local excision, and tylectomy.</li><li>➤ Breast conservative surgery</li><li>➤ segmental mastectomy, lumpectomy, partial mastectomy, wide local excision, and tylectomy.</li><li>➤ Contraindications for breast conservative surgery.</li><li>➤ Absolute contraindication:</li><li>➤ Absolute contraindication:</li><li>➤ Pregnancy, except 3 rd trimester Diffuse microcalcifications Positive pathologic margin History of therapeutic radiation exposure to chest wall Multicentric tumor</li><li>➤ Pregnancy, except 3 rd trimester</li><li>➤ Diffuse microcalcifications</li><li>➤ Positive pathologic margin</li><li>➤ History of therapeutic radiation exposure to chest wall</li><li>➤ Multicentric tumor</li><li>➤ Relative contraindication:</li><li>➤ Relative contraindication:</li><li>➤ Connective tissues disorders like systemic lupus erythematosus (SLE) and scleroderma, excluding rheumatoid arthritis Large lump-to-breast ratio, i.e., big lump in small breast Lump beneath the nipple-areola complex Multifocal tumor</li><li>➤ Connective tissues disorders like systemic lupus erythematosus (SLE) and scleroderma, excluding rheumatoid arthritis</li><li>➤ Large lump-to-breast ratio, i.e., big lump in small breast</li><li>➤ Lump beneath the nipple-areola complex</li><li>➤ Multifocal tumor</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 935, Schwartz’s principle of surgery 10 th edition Pg 538, Devita-cancer principles and practice of oncology: 10 th edition pg. 1131</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th Ed. Pg 935, Schwartz’s principle of surgery 10 th edition Pg 538, Devita-cancer principles and practice of oncology: 10 th edition pg. 1131</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following structures is not usually removed in modified radical mastectomy?", "options": [{"label": "A", "text": "Pectoralis major", "correct": true}, {"label": "B", "text": "Axillary lymph nodes", "correct": false}, {"label": "C", "text": "Nipple-areola complex", "correct": false}, {"label": "D", "text": "Pectoral fascia", "correct": false}], "correct_answer": "A. Pectoralis major", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Pectoralis major</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Axillary Lymph Nodes Axillary lymph nodes are typically removed during a modified radical mastectomy. The extent of lymph node removal includes levels I, II, and sometimes III.</li><li>• Option B: Axillary Lymph Nodes</li><li>• removed during a modified radical mastectomy.</li><li>• Option C: Nipple-areola Complex The nipple-areola complex is removed during a modified radical mastectomy to ensure the complete excision of potentially involved ductal tissue that converges towards the nipple.</li><li>• Option C: Nipple-areola Complex</li><li>• removed during a modified radical mastectomy</li><li>• Option D: Pectoral Fascia The pectoral fascia is removed during a modified radical mastectomy to ensure complete removal of breast tissue that may be intimately involved with the fascia overlying the pectoralis major muscle.</li><li>• Option D: Pectoral Fascia</li><li>• removed during a modified radical mastectomy</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In a modified radical mastectomy , the pectoralis major muscle is not removed , distinguishing it from the more extensive Halsted’s radical mastectomy.Top of Form</li><li>➤ modified radical mastectomy</li><li>➤ pectoralis major muscle is not removed</li><li>➤ Patey’s modified radical mastectomy removes:</li><li>➤ All breast tissue Nipple-areola complex Skin overlying tumor Levels I, II, and III axillary lymph nodes. Pectoralis minor.</li><li>➤ All breast tissue</li><li>➤ Nipple-areola complex</li><li>➤ Skin overlying tumor</li><li>➤ Levels I, II, and III axillary lymph nodes.</li><li>➤ Pectoralis minor.</li><li>➤ Scanlon’s modification of MRM: Pectoralis minor is cut, then sutured back</li><li>➤ Auchincloss’ modification of MRM: Pectoralis minor is retracted only.</li><li>➤ Important surgeries for breast cancer:</li><li>➤ Important surgeries for breast cancer:</li><li>➤ Lumpectomy/Wide local excision: Excision of lump with 1 cm gross margin. Simple mastectomy: Entire breast + Nipple – areola complex + overlying skin. Subcutaneous mastectomy: Palpable extent of breast without overlying skin (inframammary incision). Done for gynacomastia Modified radical mastectomy: entire breast tissue + NAC + lymph nodes (levels I + II + III) Halsted’s radical mastectomy: Entire breast tissue + Nipple- areola complex + skin +levels I + II + III axillary lymph nodes + Pectoralis major and minor.</li><li>➤ Lumpectomy/Wide local excision: Excision of lump with 1 cm gross margin.</li><li>➤ Simple mastectomy: Entire breast + Nipple – areola complex + overlying skin.</li><li>➤ Subcutaneous mastectomy: Palpable extent of breast without overlying skin (inframammary incision). Done for gynacomastia</li><li>➤ Modified radical mastectomy: entire breast tissue + NAC + lymph nodes (levels I + II + III)</li><li>➤ Halsted’s radical mastectomy: Entire breast tissue + Nipple- areola complex + skin +levels I + II + III axillary lymph nodes + Pectoralis major and minor.</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg Table 58.4, Schwartz’s principles of surgery -10 th edition page no 547</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th Ed. Pg Table 58.4, Schwartz’s principles of surgery -10 th edition page no 547</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "The most common complication following mastectomy is:", "options": [{"label": "A", "text": "Seroma", "correct": true}, {"label": "B", "text": "Lymphedema", "correct": false}, {"label": "C", "text": "Intercostobrachial nerve injury", "correct": false}, {"label": "D", "text": "Wound infection", "correct": false}], "correct_answer": "A. Seroma", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Seroma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Lymphedema Lymphedema refers to swelling that generally occurs in the arm and is caused by the removal of or damage to axillary lymph nodes during surgery , which results in a blockage in lymphatic drainage . While significant, lymphedema is less common immediately post-operatively compared to seroma formation but can be a chronic issue.</li><li>• Option B: Lymphedema</li><li>• swelling that generally occurs in the arm and is caused by the removal of or damage to axillary lymph nodes during surgery</li><li>• blockage in lymphatic drainage</li><li>• Option C: Intercostobrachial Nerve Injury: Injury to the intercostobrachial nerve can occur during mastectomy or axillary dissection , leading to numbness, paresthesia, or pain in the upper arm . It is the most common nerve injury in MRM.</li><li>• Option C: Intercostobrachial Nerve Injury:</li><li>• occur during mastectomy or axillary dissection</li><li>• numbness, paresthesia, or pain in the upper arm</li><li>• Option D: Wound Infection Postoperative wound infections can happen after any surgical procedure , including mastectomy . While these are taken very seriously, strict surgical asepsis and the use of prophylactic antibiotics have made them less frequent than seroma formation.</li><li>• Option D: Wound Infection</li><li>• happen after any surgical procedure</li><li>• mastectomy</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most common complication following mastectomy is seroma formation , occurring in up to 30% of cases due to the disruption of lymphatic drainage and local inflammatory responses post-surgery .</li><li>➤ most common complication</li><li>➤ mastectomy is seroma formation</li><li>➤ up to 30% of cases</li><li>➤ disruption of lymphatic drainage and local inflammatory responses post-surgery</li><li>➤ Seromas beneath the skin flaps or in the axilla represent the most frequent complication of mastectomy and axillary lymph node dissection. It has been reported to occur in as many as 30% of the cases.</li><li>➤ Seromas beneath the skin flaps</li><li>➤ axilla</li><li>➤ Ref : Schwartz’s principles of surgery -10 th edition page no 549, Bailey &amp; love’s short practice of surgery -27 th edition page no 281</li><li>➤ Ref</li><li>➤ : Schwartz’s principles of surgery -10 th edition page no 549, Bailey &amp; love’s short practice of surgery -27 th edition page no 281</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient underwent a modified radical mastectomy. Later she complained of loss of sensation over the medial aspect of the right upper arm. The nerve most likely damaged is:", "options": [{"label": "A", "text": "Intercostobrachial nerve", "correct": true}, {"label": "B", "text": "Long thoracic nerve", "correct": false}, {"label": "C", "text": "Thoracodorsal nerve", "correct": false}, {"label": "D", "text": "Axillary nerve", "correct": false}], "correct_answer": "A. Intercostobrachial nerve", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Intercostobrachial nerve</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Long Thoracic Nerve The long thoracic nerve innervates the serratus anterior muscle . Damage to this nerve would lead to winged scapula but would not cause sensory loss in the upper arm.</li><li>• Option B: Long Thoracic Nerve</li><li>• innervates</li><li>• serratus anterior muscle</li><li>• Option C: Thoracodorsal Nerve The thoracodorsal nerve innervates the latissimus dorsi muscle . Its injury would result in weakness of the arm adduction and internal rotation but not in sensory loss.</li><li>• Option C: Thoracodorsal Nerve</li><li>• innervates the latissimus dorsi muscle</li><li>• Option D: Axillary Nerve The axillary nerve provides motor innervation to the deltoid and teres minor muscles and sensory innervation to the regimental badge area (lateral aspect of the shoulder). Damage to this nerve would not present with loss of sensation in the medial upper arm.</li><li>• Option D: Axillary Nerve</li><li>• innervation to the deltoid and teres minor muscles</li><li>• sensory innervation to the regimental badge area</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The intercostobrachial nerve , when damaged during a modified radical mastectomy , is likely responsible for the loss of sensation over the medial aspect of the upper arm due to its sensory innervation in that area</li><li>➤ intercostobrachial nerve</li><li>➤ damaged during a modified radical mastectomy</li><li>➤ loss of sensation over the medial aspect of the upper arm</li><li>➤ sensory innervation in that area</li><li>➤ Structures preserved in MRM:</li><li>➤ Axillary vein Bell’s nerve to serratus anterior Cephalic vein Dorsal/thoracodorsal nerve and pedicle</li><li>➤ Axillary vein</li><li>➤ Bell’s nerve to serratus anterior</li><li>➤ Cephalic vein</li><li>➤ Dorsal/thoracodorsal nerve and pedicle</li><li>➤ Ref : Sabiston Textbook of surgery 20 th edition</li><li>➤ Ref</li><li>➤ : Sabiston Textbook of surgery 20 th edition</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 40-year-old female underwent modified radical mastectomy for carcinoma of breast. She is desirous of breast reconstruction. Which of these tissue flaps will yield the best outcome?", "options": [{"label": "A", "text": "Deep inferior epigastric perforators flap", "correct": true}, {"label": "B", "text": "Latissimus dorsi musculocutaneous flap", "correct": false}, {"label": "C", "text": "Transverse rectus abdominis myocutaneous flap", "correct": false}, {"label": "D", "text": "Anterolateral thigh flap", "correct": false}], "correct_answer": "A. Deep inferior epigastric perforators flap", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/22/whatsapp-image-2024-03-22-at-115354-am.jpeg"], "explanation": "<p><strong>Ans. A) Deep inferior epigastric perforators flap</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Latissimus Dorsi Musculocutaneous Flap The pedicled latissimus dorsi flap uses muscle, skin, and fat from the upper back and is tunneled to the mastectomy site to create a new breast mound. It's a reliable flap but is not the gold standard because it can lead to weakness in the back and shoulder.</li><li>• Option B: Latissimus Dorsi Musculocutaneous Flap</li><li>• pedicled latissimus dorsi flap</li><li>• muscle, skin, and fat from the upper back</li><li>• tunneled to the mastectomy site</li><li>• Option C: Transverse Rectus Abdominis Myocutaneous Flap (TRAM) The TRAM flap uses skin, fat, and a portion of the rectus abdominis muscle from the lower abdomen . It can be pedicled (attached to its original blood supply) or free (detached and reattached to blood vessels at the new site). While it is a commonly used flap, it is not the gold standard due to the risk of abdominal wall weakness.</li><li>• Option C: Transverse Rectus Abdominis Myocutaneous Flap (TRAM)</li><li>• uses skin, fat, and a portion of the rectus abdominis muscle from the lower abdomen</li><li>• Option D: Anterolateral thigh Flap It's a free flap used for complete breast reconstruction , but is not as common as DIEP flap.</li><li>• Option D: Anterolateral thigh Flap</li><li>• free flap used for complete breast reconstruction</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The gold standard for breast reconstruction with autogenous tissue is the Deep Inferior Epigastric Perforators (DIEP) flap , which uses skin and fat from the lower abdomen without sacrificing the rectus abdominis muscle , thus minimizing the risk of abdominal complications and providing a cosmetically superior result.</li><li>➤ gold standard for breast reconstruction with autogenous tissue is the Deep Inferior Epigastric Perforators</li><li>➤ flap</li><li>➤ uses skin and fat from the lower abdomen</li><li>➤ rectus abdominis muscle</li><li>➤ The gold standard in breast reconstruction with autogenous tissue is the deep inferior epigastric perforators (DIEP) flap:</li><li>➤ It is a free flap. Only subcutaneous fat and skin is taken. The rectus abdominus muscle is not removed, and hence, there is no abdominal wall weakness. Cosmetically, it is the best flap, and it has the advantage of giving a “tummy tuck” to the patient as well.</li><li>➤ It is a free flap.</li><li>➤ Only subcutaneous fat and skin is taken.</li><li>➤ The rectus abdominus muscle is not removed, and hence, there is no abdominal wall weakness.</li><li>➤ Cosmetically, it is the best flap, and it has the advantage of giving a “tummy tuck” to the patient as well.</li><li>➤ Transverse rectus abdominis myocutaneous (TRAM) flap :</li><li>➤ Transverse rectus abdominis myocutaneous</li><li>➤ flap</li><li>➤ It can be pedicled TRAM or free TRAM. Either based on superior epigastric or inferior epigastric or both (supercharged TRAM). Skin, fat, and muscle are moved to the chest.</li><li>➤ It can be pedicled TRAM or free TRAM.</li><li>➤ Either based on superior epigastric or inferior epigastric or both (supercharged TRAM).</li><li>➤ Skin, fat, and muscle are moved to the chest.</li><li>➤ The rectus abdominus muscle is excised, and hence, the procedure leads to abdominal wall weakness (hernias can occur).</li><li>➤ Ref : Bailey &amp; Love’s short practice of surgery -28 th edition page no 937-940</li><li>➤ Ref</li><li>➤ : Bailey &amp; Love’s short practice of surgery -28 th edition page no 937-940</li><li>➤ Sabiston Textbook of surgery 20 th edition page no. 868 and 869</li><li>➤ Sabiston Textbook of surgery 20 th edition page no. 868 and 869</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following models of breast cancer are used for prognosis?", "options": [{"label": "A", "text": "Nottingham index", "correct": true}, {"label": "B", "text": "Gail model", "correct": false}, {"label": "C", "text": "Claus model", "correct": false}, {"label": "D", "text": "All of the above", "correct": false}], "correct_answer": "A. Nottingham index", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Nottingham Index</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Gail Model The Gail Model is a risk assessment tool used to estimate a woman's risk of developing breast cancer . It takes into account a woman's personal medical history, her reproductive history, and the history of breast cancer among her first-degree relatives.</li><li>• Option B: Gail Model</li><li>• risk assessment tool used to estimate a woman's risk of developing breast cancer</li><li>• Option C: Claus Model The Claus Model is another risk assessment model that estimates the probability of developing breast cancer based on family history . It particularly considers the number of affected first- and second-degree relatives and their ages at diagnosis.</li><li>• Option C: Claus Model</li><li>• risk assessment model that estimates the probability of developing breast cancer based on family history</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Nottingham Prognostic Index, Gail Model, and Claus Model are all related to breast carcinoma, with the Nottingham Prognostic Index being used for prognostication in diagnosed cases , and the Gail and Claus models utilized for assessing the risk of developing breast cancer.</li><li>➤ Nottingham Prognostic Index, Gail Model, and Claus Model are all related to breast carcinoma,</li><li>➤ Nottingham Prognostic Index being used for prognostication</li><li>➤ diagnosed cases</li><li>➤ The Nottingham Prognostic index segregates the patients into four groups , and is used to predict the 10-year survival . The NPI helps clinicians in formulating treatment plans.</li><li>➤ Nottingham Prognostic index segregates the patients into four groups</li><li>➤ used to predict the 10-year survival</li><li>➤ Nottingham Prognostic Index = (0.2 x Tumor size in cm) + Grade + Nodes</li><li>➤ Nottingham Prognostic Index = (0.2 x Tumor size in cm) + Grade + Nodes</li><li>➤ The Gail and Claus models are used to assess the risk of development of breast carcinoma .</li><li>➤ Gail and Claus models are used to assess the risk of development of breast carcinoma</li><li>➤ The Gail model includes the following parameters:</li><li>➤ Number of first-degree relatives with carcinoma breast. Age at first live birth Number of breast biopsies</li><li>➤ Number of first-degree relatives with carcinoma breast.</li><li>➤ Age at first live birth</li><li>➤ Number of breast biopsies</li><li>➤ Claus model provides individual estimates of breast cancer risk according to the decade of life based on presence of first- and second- degree relatives with breast cancer and their age at diagnosis.</li><li>➤ Claus model</li><li>➤ estimates of breast cancer risk according to the decade of life based on presence of first- and second- degree relatives</li><li>➤ Neither the Gail model nor the Claus model accounts for the risk associated with mutations in the breast cancer susceptibility genes BRCA1 and BRCA2.</li><li>➤ Neither the Gail model</li><li>➤ Claus model accounts for the risk associated with mutations in the breast cancer susceptibility genes BRCA1 and BRCA2.</li><li>➤ Van Nuys Prognostic index is used to identify patients with duct carcinoma in situ (DCIS) who do not need radiation therapy.</li><li>➤ Van Nuys Prognostic index</li><li>➤ patients with duct carcinoma in situ</li><li>➤ This grading system is based on the following parameters:</li><li>➤ Patient’s age DCIS nuclear grade and presence of micro calcification Size of the lesion Width of the surgical margin</li><li>➤ Patient’s age</li><li>➤ DCIS nuclear grade and presence of micro calcification</li><li>➤ Size of the lesion</li><li>➤ Width of the surgical margin</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 942, Schwartz’s principles of surgery 10 th edition page nos 512, 513 and 536, Sabiston textbook of surgery 20 th edition page no 853.</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th Ed. Pg 942, Schwartz’s principles of surgery 10 th edition page nos 512, 513 and 536, Sabiston textbook of surgery 20 th edition page no 853.</li><li>➤ Online resource https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4473391/</li><li>➤ Online resource</li><li>➤ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4473391/</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following chemotherapeutic agents is not commonly used for chemotherapy in breast cancer?", "options": [{"label": "A", "text": "Paclitaxel", "correct": false}, {"label": "B", "text": "Cyclophosphamide", "correct": false}, {"label": "C", "text": "Cisplatin", "correct": true}, {"label": "D", "text": "Adriamycin", "correct": false}], "correct_answer": "C. Cisplatin", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Cisplatin</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Paclitaxel Paclitaxel is a taxane used commonly in breast cancer treatment . It stabilizes microtubules and prevents cell division, which is effective in treating various types of breast cancer, especially when combined with other chemotherapeutic agents.</li><li>• Option A: Paclitaxel</li><li>• taxane used commonly in breast cancer treatment</li><li>• Option B: Cyclophosphamide Cyclophosphamide is an alkylating agent that is part of many breast cancer chemotherapy regimens. It works by cross-linking DNA and RNA, thereby inhibiting cancer cell growth and multiplication.</li><li>• Option B: Cyclophosphamide</li><li>• alkylating agent that is part of many breast cancer chemotherapy regimens.</li><li>• Option D: Adriamycin (Doxorubicin) Adriamycin, or doxorubicin, is an anthracycline antibiotic commonly used in breast cancer chemotherapy. It intercalates DNA and inhibits topoisomerase II, leading to DNA damage and apoptosis of cancer cells.</li><li>• Option D: Adriamycin (Doxorubicin)</li><li>• anthracycline antibiotic commonly used in breast cancer chemotherapy.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Among the chemotherapeutic agents listed, cisplatin is not commonly used as a standard first-line therapy for breast cancer , whereas paclitaxel, cyclophosphamide, and Adriamycin are commonly included in breast cancer chemotherapy regimens.</li><li>➤ chemotherapeutic agents listed, cisplatin is not commonly used as a standard first-line therapy for breast cancer</li><li>➤ paclitaxel, cyclophosphamide, and Adriamycin</li><li>➤ breast cancer chemotherapy regimens.</li><li>➤ Present chemotherapy regimen used is ACT, i.e., Adriamycin, Cyclophosphamide, and Taxane (Paclitaxel). 4 cycles of AC followed by 4 cycles of T. Other regimens which are less commonly used currently are as follows: cyclophosphamide (C), methotrexate (M) and 5-fuorouracil (F) (CMF); anthracycline-based regimens: CAF (A, Adriamycin [doxorubicin]), CEF (E, epirubicin); Taxane (docetaxel, paclitaxel)-based regimens.</li><li>➤ Present chemotherapy regimen used is ACT, i.e., Adriamycin, Cyclophosphamide, and Taxane (Paclitaxel).</li><li>➤ 4 cycles of AC followed by 4 cycles of T.</li><li>➤ Other regimens which are less commonly used currently are as follows:</li><li>➤ cyclophosphamide (C), methotrexate (M) and 5-fuorouracil (F) (CMF);</li><li>➤ anthracycline-based regimens: CAF (A, Adriamycin [doxorubicin]), CEF (E, epirubicin);</li><li>➤ Taxane (docetaxel, paclitaxel)-based regimens.</li><li>➤ Indications for chemotherapy in carcinoma breast:</li><li>➤ Indications for chemotherapy in carcinoma breast:</li><li>➤ Tumor size of &gt; 1cm Tumor size of &gt;0.5 cm with any of Blood vessel/lymph vessel invasion ER/PR –ve Her -2/neu overexpression High grade Triple-negative breast carcinoma High recurrence score after oncotype Dx Any LN Positive CA breast</li><li>➤ Tumor size of &gt; 1cm</li><li>➤ Tumor size of &gt;0.5 cm with any of Blood vessel/lymph vessel invasion ER/PR –ve Her -2/neu overexpression High grade Triple-negative breast carcinoma High recurrence score after oncotype Dx</li><li>➤ Blood vessel/lymph vessel invasion ER/PR –ve Her -2/neu overexpression High grade Triple-negative breast carcinoma High recurrence score after oncotype Dx</li><li>➤ Blood vessel/lymph vessel invasion</li><li>➤ ER/PR –ve</li><li>➤ Her -2/neu overexpression</li><li>➤ High grade</li><li>➤ Triple-negative breast carcinoma</li><li>➤ High recurrence score after oncotype Dx</li><li>➤ Any LN Positive CA breast</li><li>➤ Any LN Positive CA breast</li><li>➤ Ref : Bailey 28 th Ed. Pg 940, Schwartz’s principle of surgery -10 th edition page no 551</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 940, Schwartz’s principle of surgery -10 th edition page no 551</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of the following are true regarding hormonal therapy in the treatment of breast cancer except?", "options": [{"label": "A", "text": "Tamoxifen is preferred in pre-menopausal women with Ca breast", "correct": false}, {"label": "B", "text": "Letrozole is preferred in post-menopausal women only", "correct": false}, {"label": "C", "text": "Hormone therapy is indicated in ER/PR + tumors only", "correct": false}, {"label": "D", "text": "No benefit in insitu breast malignancy", "correct": true}], "correct_answer": "D. No benefit in insitu breast malignancy", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) No benefit in insitu breast malignancy.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Tamoxifen is preferred in pre-menopausal women with Ca breast. This is true . Tamoxifen is a Selective Estrogen Receptor Modulator (SERM) that is commonly used in pre-menopausal women due to its ability to block the effects of estrogen in breast tissue without suppressing ovarian function.</li><li>• Option A: Tamoxifen is preferred in pre-menopausal women with Ca breast.</li><li>• true</li><li>• Option B: Letrozole is preferred in post-menopausal women only. This is also true . Letrozole is an aromatase inhibitor, which is particularly effective in post-menopausal women because it blocks the conversion of androgens to estrogens, which is the main source of estrogen in this group since the ovaries have ceased functioning.</li><li>• Option B: Letrozole is preferred in post-menopausal women only.</li><li>• true</li><li>• Option C: Hormone therapy is indicated in ER/PR + tumors only. This is true . Hormone therapies such as tamoxifen and aromatase inhibitors are indicated for estrogen receptor (ER) and/or progesterone receptor (PR) positive tumors, as these drugs work by interfering with hormonal signals that can promote cancer growth.</li><li>• Option C: Hormone therapy is indicated in ER/PR + tumors only.</li><li>• true</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Hormonal therapies like tamoxifen and aromatase inhibitors are beneficial in the treatment of hormone receptor-positive breast cancer and can reduce the risk of recurrence and contralateral breast cancer , and they also help prevent the progression of in situ to invasive carcinoma.</li><li>➤ Hormonal therapies</li><li>➤ tamoxifen and aromatase inhibitors</li><li>➤ beneficial in the treatment of hormone receptor-positive breast cancer</li><li>➤ reduce the risk of recurrence and contralateral breast cancer</li><li>➤ prevent the progression of in situ to invasive carcinoma.</li><li>➤ Aromatase inhibitors:</li><li>➤ Aromatase inhibitors:</li><li>➤ Include anastrozole, exemestane, and letrozole. Used for the treatment of breast cancer in postmenopausal women.</li><li>➤ Include anastrozole, exemestane, and letrozole.</li><li>➤ Used for the treatment of breast cancer in postmenopausal women.</li><li>➤ Mechanism of action</li><li>➤ Mechanism of action</li><li>➤ Selective aromatase inhibitors block the conversion of the hormone androstenedione into estrone by inhibition of the aromatase enzyme . This is the main mechanism of production of estrogen in postmenopausal women.</li><li>➤ Selective aromatase inhibitors block the conversion of the hormone androstenedione</li><li>➤ estrone by inhibition of the aromatase enzyme</li><li>➤ The enzyme aromatase is present in adipose tissue, breast tissue, breast tumor cells, and other sites.</li><li>➤ SERM like tamoxifen are preferred in pre-menopausal women, where AI cannot be used due to their ovarian suppression effect. Tamoxifen is a selective estrogen receptor (ER) modulator that is used for hormone receptor-positive breast cancers.</li><li>➤ SERM</li><li>➤ It exhibits selective agonistic and antagonistic activity for ER receptors:</li><li>➤ Agonist activity at uterus, bone, liver, and pituitary Antagonist activity at breast and blood vessels</li><li>➤ Agonist activity at uterus, bone, liver, and pituitary</li><li>➤ Antagonist activity at breast and blood vessels</li><li>➤ Used for:</li><li>➤ Used for:</li><li>➤ Primary prophylaxis of breast cancer in high-risk women. Reducing the risk of carcinoma in contralateral breast’. Reducing the risk of recurrence of carcinoma in ipsilateral and contralateral breasts.</li><li>➤ Primary prophylaxis of breast cancer in high-risk women.</li><li>➤ Reducing the risk of carcinoma in contralateral breast’.</li><li>➤ Reducing the risk of recurrence of carcinoma in ipsilateral and contralateral breasts.</li><li>➤ Dose: 20 mg once daily for 10 years (Earlier 5 years was the duration, but latest guidelines recommend 10 years).</li><li>➤ Dose: 20 mg once daily</li><li>➤ Adverse effects:</li><li>➤ Adverse effects:</li><li>➤ Hot flushes, most common adverse effect Endometrial carcinoma Thromboembolic events Reduced visual acuity, cataract, and retinal deposits</li><li>➤ Hot flushes, most common adverse effect</li><li>➤ Endometrial carcinoma</li><li>➤ Thromboembolic events</li><li>➤ Reduced visual acuity, cataract, and retinal deposits</li><li>➤ Hormonal therapy in breast carcinoma given for ER/PR- positive cases</li><li>➤ Hormonal therapy in breast carcinoma given for ER/PR- positive cases</li><li>➤ Reduce risk of recurrence Reduce risk of contralateral breast cancer Reduce risk of progression of in situ to invasive carcinoma</li><li>➤ Reduce risk of recurrence</li><li>➤ Reduce risk of contralateral breast cancer</li><li>➤ Reduce risk of progression of in situ to invasive carcinoma</li><li>➤ Reduce risk of progression of in situ to invasive carcinoma</li><li>➤ Ref : Sabiston textbook of surgery 20 th edition page no 858, Bailey and Love 28 th Ed. Pg 941.</li><li>➤ Ref</li><li>➤ : Sabiston textbook of surgery 20 th edition page no 858, Bailey and Love 28 th Ed. Pg 941.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is a new drug approved for metastatic hormone receptor-positive and HER-2 negative breast cancer?", "options": [{"label": "A", "text": "Herceptin", "correct": false}, {"label": "B", "text": "Palbociclib", "correct": true}, {"label": "C", "text": "Buparlisib", "correct": false}, {"label": "D", "text": "Ipatasertib", "correct": false}], "correct_answer": "B. Palbociclib", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Palbociclib</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Palbocilib is the newest drug approved for metastatic , hormone receptor-positive , HER-2/neu-negative breast cancer.</li><li>• Palbocilib</li><li>• newest drug approved for metastatic</li><li>• hormone receptor-positive</li><li>• HER-2/neu-negative breast cancer.</li><li>• It is used along with fulvestrant , a selective estrogen-receptor down regulator (SERD) based on the PALOMA 3 trial .</li><li>• used along with fulvestrant</li><li>• selective estrogen-receptor down regulator</li><li>• PALOMA 3 trial</li><li>• Advances in chemotherapy for metastatic breast cancer</li><li>• Treatment of metastatic breast cancer by targeting PI3k/AKT/m TOR pathways has led to newer chemotherapeutic drugs, which are as follows:</li><li>• Cyclin-dependent kinase 4/6 inhibitor</li><li>• Cyclin-dependent kinase 4/6 inhibitor</li><li>• Palbociclib: Approved for use with aromatase inhibitor (Letrozole) or SERD (Fulvestrant) Ribociclib: Approved for use with aromatase inhibitor (Letrozole) Abemaciclib: Approved for use with SERD (Fulvestrant)</li><li>• Palbociclib: Approved for use with aromatase inhibitor (Letrozole) or SERD (Fulvestrant)</li><li>• Palbociclib:</li><li>• Ribociclib: Approved for use with aromatase inhibitor (Letrozole)</li><li>• Abemaciclib: Approved for use with SERD (Fulvestrant)</li><li>• MTOR pathway inhibitor</li><li>• MTOR pathway inhibitor</li><li>• Everolimus: Approved for treatment of advanced/metastatic hormone receptor-positive, HER-2-negative breast cancer</li><li>• Everolimus: Approved for treatment of advanced/metastatic hormone receptor-positive, HER-2-negative breast cancer</li><li>• Everolimus:</li><li>• PhophatidyI - inositol 3 kinase (PI3k)</li><li>• PhophatidyI - inositol 3 kinase (PI3k)</li><li>• Buparlisib – Not approved, but trials are underway for treatment of metastatic breast carcinoma</li><li>• Buparlisib – Not approved, but trials are underway for treatment of metastatic breast carcinoma</li><li>• Buparlisib –</li><li>• AKT (Protein kinase B) inhibitors</li><li>• AKT (Protein kinase B) inhibitors</li><li>• Ipatasertib: Not approved, but found beneficial for metastatic triple-negative breast cancer</li><li>• Ipatasertib: Not approved, but found beneficial for metastatic triple-negative breast cancer</li><li>• Ipatasertib:</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Palbociclib is the newest drug approved for use in combination with hormonal therapies for the treatment of metastatic hormone receptor-positive , HER2-negative breast cancer .</li><li>➤ Palbociclib is the newest drug approved for use in combination with hormonal therapies</li><li>➤ treatment of metastatic hormone receptor-positive</li><li>➤ HER2-negative breast cancer</li><li>➤ Ref : Bailey 28 th Ed. Table 12.6</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Table 12.6</li><li>➤ Journal: https://www.uptodate.com/contents/treatment-approach-to-metastatic-hormone-receptor-positive-her2-negative-breast-cancer-endocrine-therapy?search=Palbocilib&amp;source=search_result&amp;selectedTitle=4~14&amp;uage_type=default&amp;display_rank=4</li><li>➤ Journal:</li><li>➤ https://www.uptodate.com/contents/treatment-approach-to-metastatic-hormone-receptor-positive-her2-negative-breast-cancer-endocrine-therapy?search=Palbocilib&amp;source=search_result&amp;selectedTitle=4~14&amp;uage_type=default&amp;display_rank=4</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "The chemotherapeutic agent of choice for a patient having breast cancer with the following results of immunohistochemistry (IHC) is:", "options": [{"label": "A", "text": "Tamoxifene", "correct": false}, {"label": "B", "text": "Trastuzumab", "correct": true}, {"label": "C", "text": "Fulvestrant", "correct": false}, {"label": "D", "text": "Palbociclib", "correct": false}], "correct_answer": "B. Trastuzumab", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/26/picture1_AjeezFR.png"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-183456.png"], "explanation": "<p><strong>Ans. B) Trastuzumab</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Tamoxifen:</li><li>• Option A. Tamoxifen:</li><li>• Tamoxifen is a selective estrogen receptor modulator (SERM) and is primarily used in hormone receptor-positive breast cancer . It is not the drug of choice for HER2-positive breast cancer.</li><li>• Tamoxifen is a selective estrogen receptor modulator (SERM) and is primarily used in hormone receptor-positive breast cancer .</li><li>• Tamoxifen</li><li>• selective estrogen receptor modulator</li><li>• primarily used in hormone receptor-positive breast cancer</li><li>• It is not the drug of choice for HER2-positive breast cancer.</li><li>• Option C. Fulvestrant:</li><li>• Option C. Fulvestrant:</li><li>• Fulvestrant is a selective estrogen receptor degrader (SERD) and is used in hormone receptor-positive breast cancer . It is not the drug of choice for HER2-positive breast cancer.</li><li>• Fulvestrant is a selective estrogen receptor degrader (SERD) and is used in hormone receptor-positive breast cancer .</li><li>• selective estrogen receptor degrader</li><li>• used in hormone receptor-positive breast cancer</li><li>• It is not the drug of choice for HER2-positive breast cancer.</li><li>• Option D. Palbociclib:</li><li>• Option D. Palbociclib:</li><li>• Palbociclib is a cyclin-dependent kinase 4/6 (CDK4/6) inhibitor and is used in hormone receptor-positive , HER2-negative breast cancer . It is not typically used as a single-agent therapy for HER2-positive breast cancer.</li><li>• Palbociclib is a cyclin-dependent kinase 4/6 (CDK4/6) inhibitor and is used in hormone receptor-positive , HER2-negative breast cancer .</li><li>• cyclin-dependent kinase 4/6</li><li>• inhibitor and is used in hormone receptor-positive</li><li>• HER2-negative breast cancer</li><li>• It is not typically used as a single-agent therapy for HER2-positive breast cancer.</li><li>• Note:</li><li>• Note:</li><li>• Hormone receptors - Estrogen receptor (ER) and progesterone receptor (PR) are present in the nucleus. Therefore, ER and PR positive breast cancer cells show dark nuclear staining on IHC.</li><li>• Hormone receptors - Estrogen receptor (ER) and progesterone receptor (PR) are present in the nucleus. Therefore, ER and PR positive breast cancer cells show dark nuclear staining on IHC.</li><li>• Ref : Bailey 28 th Ed. Pg 940, Schwartz’s principle of surgery -10 th edition page no 535</li><li>• Ref</li><li>• : Bailey 28 th Ed. Pg 940, Schwartz’s principle of surgery -10 th edition page no 535</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old lady presents to your OPD with a lump in the left breast in the upper outer quadrant, 6 x 4 cm in size. Tumor shows fixity to Pectoralis Major muscle, but not to chest wall. Axillary examination is normal. You perform MRM, with histopathology report and genetic array showing moderately differentiated ductal CA, lymph nodal metastasis and Luminal A subtype. What further treatment will you advise?", "options": [{"label": "A", "text": "Adjuvant Chemotherapy + radiotherapy", "correct": false}, {"label": "B", "text": "Adjuvant Chemotherapy + radiotherapy + anastrozole + trastuzumab", "correct": false}, {"label": "C", "text": "Adjuvant Chemotherapy + anastrozole", "correct": false}, {"label": "D", "text": "Adjuvant Chemotherapy + radiotherapy + anastrozole", "correct": true}], "correct_answer": "D. Adjuvant Chemotherapy + radiotherapy + anastrozole", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-184339.png"], "explanation": "<p><strong>Ans. D) Adjuvant Chemotherapy + radiotherapy + anastrozole</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Given scenario:</li><li>• Tumor size 6 x 4 cm implying T3 stage . Fixity to Pectoralis major doesn’t affect the T stage . All tumors of size &gt; 1 cm are given adjuvant chemotherapy. Presence of lymph node metastasis is an indication for adjuvant radiation . Luminal A subtype is ER/PR positive and Her 2 neu negative. Hence, adjuvant hormonal therapy is advised but not Transtuzumab.</li><li>• Tumor size 6 x 4 cm implying T3 stage . Fixity to Pectoralis major doesn’t affect the T stage . All tumors of size &gt; 1 cm are given adjuvant chemotherapy.</li><li>• Tumor size 6 x 4 cm implying T3 stage</li><li>• Fixity to Pectoralis major doesn’t affect the T stage</li><li>• size &gt; 1 cm are given adjuvant chemotherapy.</li><li>• Presence of lymph node metastasis is an indication for adjuvant radiation .</li><li>• Presence of lymph node metastasis</li><li>• adjuvant radiation</li><li>• Luminal A subtype is ER/PR positive and Her 2 neu negative. Hence, adjuvant hormonal therapy is advised but not Transtuzumab.</li><li>• Radiotherapy in CA breast</li><li>• Radiotherapy in CA breast</li><li>• Radiotherapy is shown to decrease the risk of locoregional and systemic recurrence and improve survival . The indications include:</li><li>• Radiotherapy</li><li>• decrease the risk of locoregional and systemic recurrence</li><li>• improve survival</li><li>• Patients with locally advanced breast cancers: T3, T4, N1, N2, N3 disease; Following BCT; After mastectomy if: tumor size ≥5 cm; skin or chest wall involvement; lymphovascular invasion (LVI), grade 3; Axillary lymph node positive for metastasis. In pathologically lymph node-negative tumors, radiotherapy after BCS is given to the breast only as a dose of 45–50.4 Gy (with or without a boost) delivered in 25 fractions or of 40–42.5 Gy delivered in 15 or 16 fractions (hypofractionation). In patients after mastectomy (T3N0M0), chest wall radiotherapy is given if the sentinel lymph nodes are negative. In patients with lymph node-positive disease locoregional radiotherapy is given covering the chest wall, supraclavicular region, internal mammary nodes and the axilla. The axilla should not be irradiated after axillary node dissection as this increases the risk of lymphoedema.</li><li>• Patients with locally advanced breast cancers: T3, T4, N1, N2, N3 disease;</li><li>• Following BCT;</li><li>• After mastectomy if: tumor size ≥5 cm; skin or chest wall involvement; lymphovascular invasion (LVI), grade 3;</li><li>• Axillary lymph node positive for metastasis.</li><li>• In pathologically lymph node-negative tumors, radiotherapy after BCS is given to the breast only as a dose of 45–50.4 Gy (with or without a boost) delivered in 25 fractions or of 40–42.5 Gy delivered in 15 or 16 fractions (hypofractionation).</li><li>• In patients after mastectomy (T3N0M0), chest wall radiotherapy is given if the sentinel lymph nodes are negative.</li><li>• In patients with lymph node-positive disease locoregional radiotherapy is given covering the chest wall, supraclavicular region, internal mammary nodes and the axilla. The axilla should not be irradiated after axillary node dissection as this increases the risk of lymphoedema.</li><li>• Ref : Bailey and Love 28 th Ed. Pg 939-940</li><li>• Ref :</li><li>• Bailey and Love 28 th Ed. Pg 939-940</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is false about radiotherapy for breast carcinoma?", "options": [{"label": "A", "text": "Given in all cases of breast conservative therapy", "correct": false}, {"label": "B", "text": "If MRM shows axillary lymph nodal metastasis, radiotherapy is given to axilla as well", "correct": true}, {"label": "C", "text": "Adjuvant radiotherapy is shown to reduce the risk of recurrence in LABC", "correct": false}, {"label": "D", "text": "Accelerated Partial Breast Irradiation (APBI) is a form of radiation therapy used in breast cancer treatment that targets only the lumpectomy cavity plus a margin around it, rather than the entire breast", "correct": false}], "correct_answer": "B. If MRM shows axillary lymph nodal metastasis, radiotherapy is given to axilla as well", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) If MRM shows axillary lymph nodal metastasis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A . All patients with BCS receive radiotherapy. BCS together with radiotherapy is called breast conservation therapy (BCT): BCS + RT = BCT .</li><li>• Option A</li><li>• All patients with</li><li>• BCS receive radiotherapy.</li><li>• BCS together</li><li>• radiotherapy is called breast conservation therapy</li><li>• BCS + RT = BCT</li><li>• Option C. Radiotherapy is shown to decrease the risk of locoregional and systemic recurrence and improve survival . The indications include the following:</li><li>• Option C. Radiotherapy</li><li>• decrease the risk of locoregional and systemic recurrence</li><li>• improve survival</li><li>• Patients with locally advanced breast cancers T3, T4, N1, N2, N3 disease; Following BCS; After mastectomy if: Tumour size ≥5 cm; skin or chest wall involvement; lymphovascular invasion (LVI), grade 3 Axillary lymph node positive for metastasis.</li><li>• Patients with locally advanced breast cancers T3, T4, N1, N2, N3 disease;</li><li>• Following BCS;</li><li>• After mastectomy if:</li><li>• Tumour size ≥5 cm; skin or chest wall involvement; lymphovascular invasion (LVI), grade 3</li><li>• Axillary lymph node positive for metastasis.</li><li>• Option D: Accelerated partial breast irradiation (APBI). APBI is a localized form of radiation delivered after lumpectomy to only the part of the breast where the tumor was removed.</li><li>• Option D: Accelerated partial breast irradiation (APBI).</li><li>• localized form of radiation delivered after lumpectomy</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• American Society for Radiation Oncology ABPI guidelines, 2016 :</li><li>• American Society for Radiation Oncology ABPI guidelines, 2016</li><li>• women 50 years or older with T1 disease and negative resected margins with a margin width of ≥2 mm, invasive ductal carcinoma, no LVI, ER positive, BRCA negative and sentinel node negative; women 50 years or older with low-risk DCIS (screen detected, low/intermediate nuclear grade, tumour size ≤2.5 cm, negative resected margin widths ≥3 mm).</li><li>• women 50 years or older with T1 disease and negative resected margins with a margin width of ≥2 mm, invasive ductal carcinoma, no LVI, ER positive, BRCA negative and sentinel node negative;</li><li>• women 50 years or older with low-risk DCIS (screen detected, low/intermediate nuclear grade, tumour size ≤2.5 cm, negative resected margin widths ≥3 mm).</li><li>• The tumour bed is irradiated along with a narrow rim of surrounding tissue so as to avoid the potentially harmful effects of irradiation on healthy tissue . It is delivered twice daily for 5 days</li><li>• tumour bed is irradiated along with a narrow rim of surrounding tissue</li><li>• avoid the potentially harmful effects of irradiation on healthy tissue</li><li>• twice daily for 5 days</li><li>• Ref : Bailey and Love 28 th Ed. Pg 935, 939-940</li><li>• Ref</li><li>• : Bailey and Love 28 th Ed. Pg 935, 939-940</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "The following image shows the boundaries of axillary lymph node dissection. The inferior boundary marked as ‘A’ denotes:", "options": [{"label": "A", "text": "Axillary vein", "correct": false}, {"label": "B", "text": "Thoracodorsal pedicle", "correct": false}, {"label": "C", "text": "Angular vein", "correct": true}, {"label": "D", "text": "Costoclavicular ligament", "correct": false}], "correct_answer": "C. Angular vein", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/22/whatsapp-image-2024-03-22-at-115355-am-1.jpeg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-184914.png"], "explanation": "<p><strong>Ans. C) Angular vein</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• The space of axillary lymph node dissection is inferiorly bounded by the angular vein (marked as ‘A’).</li><li>• space of axillary lymph node dissection</li><li>• inferiorly bounded by the angular vein</li><li>• Boundaries of axillary lymph node dissection are as follows.</li><li>• Superior: Axillary vein Lateral: Thoracodorsal pedicle Medial: Costoclavicular ligament (Halsted ligament) Inferior: Angular vein</li><li>• Superior: Axillary vein</li><li>• Lateral: Thoracodorsal pedicle</li><li>• Medial: Costoclavicular ligament (Halsted ligament)</li><li>• Inferior: Angular vein</li><li>• A minimum of 10 lymph nodes are removed during axillary clearance .</li><li>• minimum of 10 lymph nodes are removed during axillary clearance</li><li>• Ref : Journal https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3244245/</li><li>• Ref : Journal https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3244245/</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 38-year-old woman underwent treatment for breast cancer of 1.2 x 1 cm with positive axillary nodes. She completed radiotherapy and chemotherapy and is now receiving tamoxifen. Which investigation will you use for follow-up in the patient?", "options": [{"label": "A", "text": "Annual mammogram", "correct": true}, {"label": "B", "text": "Regular checking of LFT once in 6 months", "correct": false}, {"label": "C", "text": "Follow-up with tumor markers once in 6 months", "correct": false}, {"label": "D", "text": "Yearly bone scans", "correct": false}], "correct_answer": "A. Annual mammogram", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Annual mammogram</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Regular Checking of Liver Function Tests (LFTs) Once in 6 Months. Routine liver function tests are not standard in the follow-up of breast cancer patients unless there are specific clinical indications or if the patient is experiencing symptoms suggestive of metastatic disease or complications related to systemic therapies.</li><li>• Option B: Regular Checking of Liver Function Tests (LFTs) Once in 6 Months.</li><li>• Routine liver function tests</li><li>• not standard in the follow-up of breast cancer</li><li>• Option C: Follow-up with Tumor Markers Once in 6 Months The use of tumor markers for routine follow-up in asymptomatic patients after primary treatment for breast cancer is not recommended. They have not been shown to provide a survival benefit in this setting.</li><li>• Option C: Follow-up with Tumor Markers Once in 6 Months</li><li>• use of tumor markers for routine follow-up in asymptomatic patients</li><li>• after primary treatment</li><li>• breast cancer</li><li>• Option D: Yearly Bone Scans Routine bone scans are not indicated for follow-up in asymptomatic breast cancer patients after primary treatment . They are reserved for patients with symptoms or clinical findings that suggest bone metastasis.</li><li>• Option D: Yearly Bone Scans</li><li>• Routine bone scans</li><li>• not indicated for follow-up in asymptomatic breast cancer patients after primary treatment</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Follow-up of patients after treatment of breast cancer consists of routine physical examination once in 3 months for a year and annual mammogram.</li><li>➤ Follow-up of patients after treatment of breast cancer</li><li>➤ routine physical examination once in 3 months for a year and annual mammogram.</li><li>➤ Mammography is the only imaging modality necessary for follow-up after breast cancer surgery . There is currently no role for tumor markers, serum investigations, or any other imaging studies like bone scan in follow-up.</li><li>➤ Mammography</li><li>➤ only imaging modality</li><li>➤ follow-up after breast cancer surgery</li><li>➤ Guidelines for follow-up:</li><li>➤ Guidelines for follow-up:</li><li>➤ Physical examination:</li><li>➤ Physical examination:</li><li>➤ For the first 2 years: once every 3 to 6 months For 3-5 years: once every 6 to 12 months after 5 years: Annually</li><li>➤ For the first 2 years: once every 3 to 6 months</li><li>➤ For 3-5 years: once every 6 to 12 months after 5 years: Annually</li><li>➤ Mammography:</li><li>➤ Mammography:</li><li>➤ Initially, 6 months after surgery Thereafter, annually.</li><li>➤ Initially, 6 months after surgery</li><li>➤ Thereafter, annually.</li><li>➤ Ref : Bailey &amp; Love’s short practice of surgery 27 th edition Pg 879</li><li>➤ Ref</li><li>➤ : Bailey &amp; Love’s short practice of surgery 27 th edition Pg 879</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Thrombophlebitis of the superficial veins of the breast typically affects which of the below?", "options": [{"label": "A", "text": "Internal mammary vein", "correct": false}, {"label": "B", "text": "Lateral thoracic vein", "correct": true}, {"label": "C", "text": "Superior epigastric vein", "correct": false}, {"label": "D", "text": "Axillary vein", "correct": false}], "correct_answer": "B. Lateral thoracic vein", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Lateral thoracic vein</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Mondor’s disease is thrombophlebitis of the superficial veins of the breast and anterior chest wall , the most commonly involved vein being the lateral thoracic vein . It is a benign, non-cancerous lesion, which is self-limiting.</li><li>• Mondor’s disease</li><li>• thrombophlebitis of the superficial veins</li><li>• breast and anterior chest wall</li><li>• most commonly involved vein being the lateral thoracic vein</li><li>• benign, non-cancerous lesion, which is self-limiting.</li><li>• Clinical feature:</li><li>• Clinical feature:</li><li>• Pain and tenderness : The affected area may be painful to the touch and may feel tender. Redness and swelling : The skin over the affected vein may appear red and swollen. Hardness and cord-like feel: The affected vein may feel hard and cord-like under the skin. Palpable lump : A palpable lump may be felt in the affected area. Discoloration: The skin over the affected vein may appear blue or purple. Itching or burning : Some patients may experience itching or burning in the affected area. Fever : In rare cases, patients may experience a low-grade fever.</li><li>• Pain and tenderness : The affected area may be painful to the touch and may feel tender.</li><li>• Pain and tenderness</li><li>• Redness and swelling : The skin over the affected vein may appear red and swollen.</li><li>• Redness and swelling</li><li>• Hardness and cord-like feel: The affected vein may feel hard and cord-like under the skin.</li><li>• Hardness and cord-like feel:</li><li>• Palpable lump : A palpable lump may be felt in the affected area.</li><li>• Palpable lump</li><li>• Discoloration: The skin over the affected vein may appear blue or purple.</li><li>• Discoloration:</li><li>• Itching or burning : Some patients may experience itching or burning in the affected area.</li><li>• Itching or burning</li><li>• Fever : In rare cases, patients may experience a low-grade fever.</li><li>• Fever</li><li>• Management:</li><li>• Management:</li><li>• Supportive measures : The affected breast should be supported with a well-fitting bra or compression garment to reduce discomfort and promote healing. Pain relief : Over-the-counter pain medications such as acetaminophen or ibuprofen can be taken to relieve pain and reduce inflammation. Warm compresses : Applying warm compresses to the affected area for 15-20 minutes several times a day for 4-6 weeks can help relieve pain and promote healing.</li><li>• Supportive measures : The affected breast should be supported with a well-fitting bra or compression garment to reduce discomfort and promote healing.</li><li>• Supportive measures</li><li>• Pain relief : Over-the-counter pain medications such as acetaminophen or ibuprofen can be taken to relieve pain and reduce inflammation.</li><li>• Pain relief</li><li>• Warm compresses : Applying warm compresses to the affected area for 15-20 minutes several times a day for 4-6 weeks can help relieve pain and promote healing.</li><li>• Warm compresses</li><li>• Ref : Bailey and love’s short practice of surgery -27 th edition page no 867, Bailey 28 th Ed. Pg 930.</li><li>• Ref</li><li>• : Bailey and love’s short practice of surgery -27 th edition page no 867, Bailey 28 th Ed. Pg 930.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Pathologic nipple discharge in the non-lactating breast is most commonly associated with which cause?", "options": [{"label": "A", "text": "Intraductal papilloma", "correct": true}, {"label": "B", "text": "Duct ectasia", "correct": false}, {"label": "C", "text": "Carcinoma i", "correct": false}, {"label": "D", "text": "Galactorrhea", "correct": false}], "correct_answer": "A. Intraductal papilloma", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Intraductal papilloma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Duct Ectasia Duct ectasia, which is the dilatation of the milk ducts , can cause a thick, sticky discharge that may be gray to green in color . It is more common in perimenopausal women and is the second most common cause of pathologic nipple discharge after intraductal papilloma.</li><li>• Option B: Duct Ectasia</li><li>• dilatation of the milk ducts</li><li>• thick, sticky discharge that may be gray to green in color</li><li>• Option C: Carcinoma While breast carcinoma can cause nipple discharge, it is less common than intraductal papilloma and duct ectasia as a cause for this symptom. When carcinoma is the cause, the discharge may be bloody or clear, and there are often other signs such as a breast mass or changes in the skin.</li><li>• Option C: Carcinoma</li><li>• cause nipple discharge, it is less common than intraductal papilloma and duct ectasia</li><li>• Option D: Galactorrhea Galactorrhea is the production of breast milk in men or in women who are not breastfeeding. It is not typically associated with pathologic nipple discharge unless related to an underlying pathology like a prolactinoma.</li><li>• Option D: Galactorrhea</li><li>• production of breast milk in men or in women who are not breastfeeding.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Intraductal papilloma is the most common cause of pathologic nipple discharge in the non-lactating breast , often presenting as bloody or serous discharge , and typically requires surgical excision for both diagnostic and therapeutic purposes.</li><li>➤ Intraductal papilloma</li><li>➤ most common cause of pathologic nipple discharge</li><li>➤ non-lactating breast</li><li>➤ presenting as bloody or serous discharge</li><li>➤ requires surgical excision for both diagnostic and therapeutic purposes.</li><li>➤ An intraductal papilloma is a true polyp of the epithelium-lined ducts of the breast . Most papillomas are small, with diameters &lt;1 cm, but they can grow up 4 or 5 cm in diameter. Papilloma located close to the nipple are often accompanied by a blood stained nipple discharge and is the most common cause of bloody nipple discharge. However, they are not associated with an increased risk of breast cancer. The treatment usually involves excision through a circumareolar incision. Direct quote: “Intraductal papilloma is the most common cause of pathologic nipple discharge, accounting for 35% to 48% of causes, followed by duct ectasia (17%-36%)”- ACR appropriateness criteria, evaluation of nipple discharge</li><li>➤ An intraductal papilloma is a true polyp of the epithelium-lined ducts of the breast . Most papillomas are small, with diameters &lt;1 cm, but they can grow up 4 or 5 cm in diameter.</li><li>➤ intraductal papilloma</li><li>➤ true polyp of the epithelium-lined ducts of the breast</li><li>➤ Papilloma located close to the nipple are often accompanied by a blood stained nipple discharge and is the most common cause of bloody nipple discharge. However, they are not associated with an increased risk of breast cancer.</li><li>➤ The treatment usually involves excision through a circumareolar incision.</li><li>➤ treatment usually involves excision through a circumareolar incision.</li><li>➤ Direct quote: “Intraductal papilloma is the most common cause of pathologic nipple discharge, accounting for 35% to 48% of causes, followed by duct ectasia (17%-36%)”- ACR appropriateness criteria, evaluation of nipple discharge</li><li>➤ Ref : Sabiston textbook of surgery 20 th edition page no 825, 836</li><li>➤ Ref</li><li>➤ : Sabiston textbook of surgery 20 th edition page no 825, 836</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 38-year-old female presents with a chief complaint of persistent breast discomfort. On examination, there is localized tenderness, erythema, and a palpable breast lump. Nipple shows slit like retraction with fish mouth appearance. Which of the following findings is most likely risk factor in this patient?", "options": [{"label": "A", "text": "A history of smoking", "correct": true}, {"label": "B", "text": "A history of recent breastfeeding", "correct": false}, {"label": "C", "text": "A history of hormonal contraceptive use", "correct": false}, {"label": "D", "text": "A history of recent trauma", "correct": false}], "correct_answer": "A. A history of smoking", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-190546.png"], "explanation": "<p><strong>Ans. A) A history of smoking</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Breast feeding is linked to mastitis or breast abscess</li><li>• Option B: Breast feeding</li><li>• linked to mastitis or breast abscess</li><li>• Option C: Hormonal contraceptive are associated with breast carcinoma , although the risk is small</li><li>• Option C: Hormonal contraceptive</li><li>• breast carcinoma</li><li>• Option D: Recent trauma or hematoma may lead to traumatic fat necrosis .</li><li>• Option D: Recent trauma</li><li>• hematoma</li><li>• traumatic fat necrosis</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Duct ectasia , characterized by the dilation of lactiferous ducts and periductal inflammation , is the most common cause of greenish nipple discharge in the non-lactating breast , particularly in women above 50 years of age .</li><li>➤ Duct ectasia</li><li>➤ dilation of lactiferous ducts and periductal inflammation</li><li>➤ most common cause of greenish nipple discharge</li><li>➤ non-lactating breast</li><li>➤ women above 50 years of age</li><li>➤ Duct ectasia (periductal mastitis) involves dilatation of multiple ducts , which is often associated with periductal inflammation.</li><li>➤ Duct ectasia</li><li>➤ dilatation of multiple ducts</li><li>➤ periductal inflammation.</li><li>➤ Most common age group affected : above 50 years . Most common presenting feature : nipple discharge</li><li>➤ Most common age group affected : above 50 years .</li><li>➤ age group affected</li><li>➤ above 50 years</li><li>➤ Most common presenting feature : nipple discharge</li><li>➤ presenting feature</li><li>➤ nipple discharge</li><li>➤ The patient presents with central non-cyclical pain, pus discharge from the nipple and a subareolar tender mass / abscess or mammary duct fistula. The examination reveals a tender, firm subareolar lump or abscess, purulent nipple discharge, thickened tender major milk ducts and a transverse slit-like nipple retraction looking like a fish’s mouth Ultrasonography shows thickened major milk ducts with surrounding inflammation or abscess. A lump should be biopsied under ultrasound guidance to confirm the diagnosis. The treatment for duct ectasia is Hadfield’s operation , which refers to the cone excision of the major duct system or sub areolar resection. All lactiferous ducts under the nipple are removed. This procedure is performed when the duct of origin for the nipple bleeding is uncertain or when there is bleeding or discharge from multiple ducts. If a single duct is involved , then microdochectomy is the treatment of choice .</li><li>➤ The patient presents with central non-cyclical pain, pus discharge from the nipple and a subareolar tender mass / abscess or mammary duct fistula.</li><li>➤ central non-cyclical pain, pus discharge from the nipple and a subareolar tender mass</li><li>➤ The examination reveals a tender, firm subareolar lump or abscess, purulent nipple discharge, thickened tender major milk ducts and a transverse slit-like nipple retraction looking like a fish’s mouth</li><li>➤ transverse slit-like nipple retraction looking like a fish’s mouth</li><li>➤ Ultrasonography shows thickened major milk ducts with surrounding inflammation or abscess. A lump should be biopsied under ultrasound guidance to confirm the diagnosis.</li><li>➤ Ultrasonography</li><li>➤ thickened major milk ducts</li><li>➤ The treatment for duct ectasia is Hadfield’s operation , which refers to the cone excision of the major duct system or sub areolar resection. All lactiferous ducts under the nipple are removed.</li><li>➤ Hadfield’s operation</li><li>➤ All lactiferous ducts under the nipple are removed.</li><li>➤ This procedure is performed when the duct of origin for the nipple bleeding is uncertain or when there is bleeding or discharge from multiple ducts.</li><li>➤ If a single duct is involved , then microdochectomy is the treatment of choice .</li><li>➤ single duct is involved</li><li>➤ microdochectomy is the treatment of choice</li><li>➤ Remember:</li><li>➤ Remember:</li><li>➤ The most common cause of blood-stained discharge from a single duct is duct papilloma . The most common cause of blood-stained discharge from multiple ducts is duct carcinoma. The most common cause of serous discharge from the breast is fibrocystic disease of the breast. Single duct single breast serous or sanguineous (4S) nipple discharge is considered pathological</li><li>➤ The most common cause of blood-stained discharge from a single duct is duct papilloma .</li><li>➤ most common cause of blood-stained discharge</li><li>➤ single duct is duct papilloma</li><li>➤ The most common cause of blood-stained discharge from multiple ducts is duct carcinoma.</li><li>➤ most common cause of blood-stained discharge</li><li>➤ multiple ducts</li><li>➤ The most common cause of serous discharge from the breast is fibrocystic disease of the breast.</li><li>➤ most common cause of serous discharge</li><li>➤ breast is fibrocystic disease</li><li>➤ Single duct single breast serous or sanguineous (4S) nipple discharge is considered pathological</li><li>➤ Single duct single breast serous or sanguineous</li><li>➤ Ref : Bailey and love’s short practice of surgery -27 th edition page no 864, 867. 28 th Ed. Pg 927.</li><li>➤ Ref</li><li>➤ : Bailey and love’s short practice of surgery -27 th edition page no 864, 867. 28 th Ed. Pg 927.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the incorrect statement with respect to a fibroadenoma of breast:", "options": [{"label": "A", "text": "Benign neoplasm", "correct": false}, {"label": "B", "text": "Multiple diffuse mass", "correct": true}, {"label": "C", "text": "Biphasic pathology", "correct": false}, {"label": "D", "text": "Peak incidence in second decade", "correct": false}], "correct_answer": "B. Multiple diffuse mass", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/26/picture1_prwkst3.png"], "explanation": "<p><strong>Ans. B) Multiple diffuse mass</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Benign neoplasm This statement is correct . A fibroadenoma is a benign breast tumor and is one of the most common benign tumors found in the breast, especially in younger women.</li><li>• Option A. Benign neoplasm</li><li>• correct</li><li>• Option C. Biphasic pathology This statement is correct . Fibroadenomas are biphasic, meaning they are composed of both stromal (connective tissue) and glandular (epithelial) components.</li><li>• Option C. Biphasic pathology</li><li>• correct</li><li>• Option D. Peak incidence in second decade This statement is correct . The peak incidence of fibroadenoma is in the second decade of life, making it a common finding in young women.</li><li>• Option D. Peak incidence in second decade</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Fibroadenomas are benign breast neoplasms that typically present as solitary, discrete, and mobile masses , commonly occurring in young women in their second decade of life , characterized by biphasic pathology with both stromal and epithelial components .</li><li>➤ Fibroadenomas</li><li>➤ benign breast neoplasms</li><li>➤ present as solitary, discrete, and mobile masses</li><li>➤ young women in their second decade of life</li><li>➤ biphasic pathology</li><li>➤ both stromal and epithelial components</li><li>➤ It is a form of aberrations of normal development and involution of breast (ANDI). Most common age group affected is 15-25 years (early reproductive period) with peak incidence in the second decade. It arises from hyperplasia of a single lobule and presents as a well circumscribed, smooth, firm, non tender, freely mobile mass (mouse in the breast). It is a biphasic tumor consisting of fibroblastic stroma and epithelium-lined gland. Popcorn calcification is seen in mammography. Excision is not advised unless there is suspicious histology on FNAC. Giant fibroadenoma are &gt;5cm in size, common in adolescent girls and require excision by sub mammary incision.</li><li>➤ It is a form of aberrations of normal development and involution of breast (ANDI).</li><li>➤ form of aberrations of normal development</li><li>➤ involution of breast</li><li>➤ Most common age group affected is 15-25 years (early reproductive period) with peak incidence in the second decade.</li><li>➤ age group affected is 15-25 years</li><li>➤ It arises from hyperplasia of a single lobule and presents as a well circumscribed, smooth, firm, non tender, freely mobile mass (mouse in the breast).</li><li>➤ arises from hyperplasia of a single lobule</li><li>➤ presents as a well circumscribed, smooth, firm, non tender, freely mobile mass</li><li>➤ It is a biphasic tumor consisting of fibroblastic stroma and epithelium-lined gland.</li><li>➤ Popcorn calcification is seen in mammography.</li><li>➤ Excision is not advised unless there is suspicious histology on FNAC.</li><li>➤ Excision is not advised</li><li>➤ Giant fibroadenoma are &gt;5cm in size, common in adolescent girls and require excision by sub mammary incision.</li><li>➤ Popcorn calcification on mammography:</li><li>➤ Ref : Bailey &amp; love’s short practice of surgery -27 th edition page no 868</li><li>➤ Ref</li><li>➤ : Bailey &amp; love’s short practice of surgery -27 th edition page no 868</li><li>➤ Robbins basic pathology, 10 th edition page no 738</li><li>➤ Robbins basic pathology, 10 th edition page no 738</li><li>➤ Schwartz’s principles of surgery -10 th edition page no 507</li><li>➤ Schwartz’s principles of surgery -10 th edition page no 507</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following statements is false about cystosarcoma phyllodes?", "options": [{"label": "A", "text": "Can be benign or malignant", "correct": false}, {"label": "B", "text": "Commonly metastasizes to axillary lymph nodes", "correct": true}, {"label": "C", "text": "Mixed neoplasm having both epithelial and mesenchymal elements", "correct": false}, {"label": "D", "text": "Treatment is wide excision with 2 cm margin", "correct": false}], "correct_answer": "B. Commonly metastasizes to axillary lymph nodes", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Commonly metastasizes to axillary lymph nodes</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Can be benign or malignant This statement is true . Phyllodes tumors can be benign, borderline, or malignant based on histological features such as stromal cellularity, atypia, mitotic activity, and the nature of the tumor borders.</li><li>• Option A: Can be benign or malignant</li><li>• true</li><li>• Option C: Mixed neoplasm having both epithelial and mesenchymal elements This statement is true . Phyllodes tumors are characterized by their biphasic nature, having both stromal (mesenchymal) and epithelial components.</li><li>• Option C: Mixed neoplasm having both epithelial and mesenchymal elements</li><li>• true</li><li>• Option D: Treatment is wide excision with 2 margin This statement is true . The treatment of choice for phyllodes tumors is wide local excision with clear margins (&gt;2cm) to minimize the risk of local recurrence. Mastectomy may be considered for larger or recurrent tumors.</li><li>• Option D: Treatment is wide excision with 2 margin</li><li>• true</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Cystosarcoma phyllodes are fibroepithelial neoplasms of the breast that can range from benign to malignant , are composed of both epithelial and mesenchymal elements , and typically metastasize through the bloodstream rather than the lymphatic system . The recommended treatment is wide excision with a margin to prevent recurrence.</li><li>➤ Cystosarcoma phyllodes are fibroepithelial neoplasms of the breast</li><li>➤ range from benign to malignant</li><li>➤ composed of both epithelial and mesenchymal elements</li><li>➤ metastasize through the bloodstream</li><li>➤ lymphatic system</li><li>➤ Phyllodes tumor (sero-cystic disease of brodie or cyst sarcoma phyllodes):</li><li>➤ It originates from hormonally responsive stromal cells of the breast and are usually benign. Affects women &gt;40 years of age usually. Histologically, Phyllodes tumours are classified according to histological behaviour into benign (mitotic rate &lt;4 per 10 high-power fields [HPF]), borderline (mitotic rate 4–9 per 10 HPF) and malignant (mitotic rate &gt;10 per 10 HPF) tumours. Clinical features: Large, sometimes massive, with an unevenly bosselated surface Ulceration of overlying skin occurs because of pressure necrosis Remains mobile on the chest wall Treatment: Tumors are treated by excision with margins of at least 2 cm to prevent local recurrence.</li><li>➤ It originates from hormonally responsive stromal cells of the breast and are usually benign.</li><li>➤ Affects women &gt;40 years of age usually.</li><li>➤ Histologically, Phyllodes tumours are classified according to histological behaviour into benign (mitotic rate &lt;4 per 10 high-power fields [HPF]), borderline (mitotic rate 4–9 per 10 HPF) and malignant (mitotic rate &gt;10 per 10 HPF) tumours.</li><li>➤ Clinical features: Large, sometimes massive, with an unevenly bosselated surface Ulceration of overlying skin occurs because of pressure necrosis Remains mobile on the chest wall</li><li>➤ Clinical features:</li><li>➤ Large, sometimes massive, with an unevenly bosselated surface Ulceration of overlying skin occurs because of pressure necrosis Remains mobile on the chest wall</li><li>➤ Large, sometimes massive, with an unevenly bosselated surface</li><li>➤ Ulceration of overlying skin occurs because of pressure necrosis</li><li>➤ Remains mobile on the chest wall</li><li>➤ Treatment: Tumors are treated by excision with margins of at least 2 cm to prevent local recurrence.</li><li>➤ Treatment:</li><li>➤ Tumors are treated by excision with margins of at least 2 cm to prevent local recurrence.</li><li>➤ Tumors are treated by excision with margins of at least 2 cm to prevent local recurrence.</li><li>➤ Ref : Schwartz’s principles of surgery -10 th edition page no 555, 1481</li><li>➤ Ref</li><li>➤ : Schwartz’s principles of surgery -10 th edition page no 555, 1481</li><li>➤ Bailey &amp; love’s short practice of surgery -28 th Ed. Pg 922 .</li><li>➤ Bailey &amp; love’s short practice of surgery -28 th Ed. Pg 922</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A female patient presents with a breast abscess. USG revealed an abscess cavity of 40 cc volume and 4 cm in diameter. What will be your next step in management?", "options": [{"label": "A", "text": "Aspiration", "correct": false}, {"label": "B", "text": "Continue antibiotics only", "correct": false}, {"label": "C", "text": "A Suction catheter drainage", "correct": true}, {"label": "D", "text": "Incision and drainage under general anesthesia", "correct": false}], "correct_answer": "C. A Suction catheter drainage", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Suction catheter drainage</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Aspiration Aspiration is a less invasive procedure that can be used for smaller abscesses , typically those less than 3 cm in diameter . It can be done under local anesthesia and often requires several sessions, along with antibiotic therapy.</li><li>• Option A: Aspiration</li><li>• less invasive procedure that can be used for smaller abscesses</li><li>• less than 3 cm in diameter</li><li>• Option B: Continue Antibiotics Only Continuing with antibiotics alone may be considered when only mastitis is present, and the patient is not showing signs of systemic infection.</li><li>• Option B: Continue Antibiotics Only</li><li>• alone</li><li>• considered when only mastitis is present,</li><li>• Option D: Incision and Drainage Under General Anesthesia Incision and drainage under general anesthesia is usually reserved for larger abscesses or when there's thick pus , resistant bacteria , a failure of other methods , or specific indications like a multiloculated abscess. It's a more invasive procedure and typically the last resort when other less invasive measures fail.</li><li>• Option D: Incision and Drainage Under General Anesthesia</li><li>• general anesthesia is usually reserved for larger abscesses</li><li>• when there's thick pus</li><li>• resistant bacteria</li><li>• failure of other methods</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ For a breast abscess of significant size , as indicated by ultrasound findings , the preferred initial step in management is suction catheter drainage , which allows for minimally invasive resolution of the abscess and can enable the patient to continue breastfeeding, with incision and drainage reserved for cases where less invasive measures are unsuccessful.</li><li>➤ breast abscess</li><li>➤ significant size</li><li>➤ ultrasound findings</li><li>➤ preferred initial step in management is suction catheter drainage</li><li>➤ minimally invasive resolution of the abscess</li><li>➤ enable the patient to continue breastfeeding,</li><li>➤ The latest guidelines for the management of breast abscess specify that multiple aspirations under antibiotic cover should be attempted before an incision and drainage is done. This often allows resolution without the need for an incision scar and also allows the patient to carry on breastfeeding. “In abscesses &gt;3 cm in diameter or those containing more than 30 mL of pus (assessed on ultrasonography), a vacuum suction catheter is inserted under ultrasound guidance to drain the pus. The patient should be reviewed on alternate days by clinical examination and ultrasonography. Any residual collection should be aspirated. The antibiotics are modified according to the microbiological culture report. In patients with a suction drain, the catheter is irrigated with cold normal saline (cold to reduce pain) on each visit until complete resolution. Antibiotics should be continued for 14 days.”</li><li>➤ The latest guidelines for the management of breast abscess specify that multiple aspirations under antibiotic cover should be attempted before an incision and drainage is done. This often allows resolution without the need for an incision scar and also allows the patient to carry on breastfeeding.</li><li>➤ “In abscesses &gt;3 cm in diameter or those containing more than 30 mL of pus (assessed on ultrasonography), a vacuum suction catheter is inserted under ultrasound guidance to drain the pus. The patient should be reviewed on alternate days by clinical examination and ultrasonography. Any residual collection should be aspirated. The antibiotics are modified according to the microbiological culture report. In patients with a suction drain, the catheter is irrigated with cold normal saline (cold to reduce pain) on each visit until complete resolution. Antibiotics should be continued for 14 days.”</li><li>➤ Incision and drainage of abscess is performed only if :</li><li>➤ Incision and drainage of abscess is performed only if</li><li>➤ Presence of thick pus Bacteria resistant to antibiotics. The most common organism responsible for breast abscess is S. aureus. If just the superficial part has been aspirated in the presence of a multiloculated abscess. A non-healing breast abscess due to tuberculosis of breast or inflammatory carcinoma of the breast, or an immunocompromised host.</li><li>➤ Presence of thick pus</li><li>➤ Bacteria resistant to antibiotics. The most common organism responsible for breast abscess is S. aureus.</li><li>➤ If just the superficial part has been aspirated in the presence of a multiloculated abscess.</li><li>➤ A non-healing breast abscess due to tuberculosis of breast or inflammatory carcinoma of the breast, or an immunocompromised host.</li><li>➤ Ref : Bailey &amp; love’s short practice of surgery -28 th edition page no 927.</li><li>➤ Ref</li><li>➤ : Bailey &amp; love’s short practice of surgery -28 th edition page no 927.</li><li>➤ Online resource: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3900741/ https://www.jmedsoc.org/article.asp?issn=0972-4958;year=2012;volume=26;issue=3;spage=189;epage=191;aulast=singh</li><li>➤ Online resource: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3900741/ https://www.jmedsoc.org/article.asp?issn=0972-4958;year=2012;volume=26;issue=3;spage=189;epage=191;aulast=singh</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "What will be your next step in the management of a large breast cyst in a 60-year-old woman which reveals haemorrhagic fluid on aspiration?", "options": [{"label": "A", "text": "Wait for refilling and attempt aspiration again", "correct": false}, {"label": "B", "text": "Core biopsy", "correct": true}, {"label": "C", "text": "Supportive management", "correct": false}, {"label": "D", "text": "Mastectomy and SLNB", "correct": false}], "correct_answer": "B. Core biopsy", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Core biopsy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Wait for Refilling and Attempt Aspiration Again This option would not be appropriate for a hemorrhagic fluid aspirate , as the presence of blood necessitates further evaluation to rule out malignancy.</li><li>• Option A: Wait for Refilling and Attempt Aspiration Again</li><li>• hemorrhagic fluid aspirate</li><li>• Option C: Supportive Management Supportive management alone would not be adequate without further diagnostic evaluation in the presence of hemorrhagic fluid , as it could indicate an underlying malignancy.</li><li>• Option C: Supportive Management</li><li>• alone would not be adequate without further diagnostic evaluation in the presence of hemorrhagic fluid</li><li>• Option D: Mastectomy and Sentinel Lymph Node Biopsy (SLNB) Mastectomy and SLNB are major surgical interventions that are not indicated solely based on the aspiration of hemorrhagic fluid from a breast cyst . These procedures are considered only after a definitive diagnosis of malignancy has been established.</li><li>• Option D: Mastectomy and Sentinel Lymph Node Biopsy (SLNB)</li><li>• major surgical interventions</li><li>• not indicated solely based on the aspiration of hemorrhagic fluid from a breast cyst</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ When hemorrhagic fluid is aspirated from a large breast cyst , a core biopsy is indicated to rule out malignancy , such as cystadenocarcinoma , and to guide subsequent management decisions based on histopathological findings.</li><li>➤ When hemorrhagic fluid is aspirated from a large breast cyst</li><li>➤ core biopsy</li><li>➤ rule out malignancy</li><li>➤ cystadenocarcinoma</li><li>➤ In a large breast cyst, if the aspirate is blood stained then core biopsy or excision should be performed and the resulting tissue should be sent for histopathology for exclusion of cystadenocarcinoma, most commonly in elderly women. However, if the aspirate is clear or there is no evidence of refilling then it can be left as such. “A smooth-walled cyst without any solid component in its wall is classified as BI-RADS 2 and requires only observation without biopsy. The presence of a solid component in the cyst wall is classified as a complex cyst and necessitates a core biopsy to rule out cystadenocarcinoma. This should be distinguished from a complicated cyst, which is defined as a cyst containing intracystic floating debris that moves within the cyst with change of posture.”</li><li>➤ In a large breast cyst, if the aspirate is blood stained then core biopsy or excision should be performed and the resulting tissue should be sent for histopathology for exclusion of cystadenocarcinoma, most commonly in elderly women.</li><li>➤ However, if the aspirate is clear or there is no evidence of refilling then it can be left as such.</li><li>➤ “A smooth-walled cyst without any solid component in its wall is classified as BI-RADS 2 and requires only observation without biopsy. The presence of a solid component in the cyst wall is classified as a complex cyst and necessitates a core biopsy to rule out cystadenocarcinoma. This should be distinguished from a complicated cyst, which is defined as a cyst containing intracystic floating debris that moves within the cyst with change of posture.”</li><li>➤ “A smooth-walled cyst without any solid component in its wall is classified as BI-RADS 2 and requires only observation without biopsy.</li><li>➤ Ref : Bailey &amp; love’s short practice of surgery -27 th edition pg 869</li><li>➤ Ref</li><li>➤ : Bailey &amp; love’s short practice of surgery -27 th edition pg 869</li><li>➤ Bailey 28 th Ed. Pg 921</li><li>➤ Bailey 28 th Ed. Pg 921</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A surgeon inserts a probe into the duct from which the discharge is emerging. He makes a tennis racquet incision and dissects the flap to reach the duct. Finally, he excises the duct. What is this procedure known as?", "options": [{"label": "A", "text": "Macrodochectomy", "correct": false}, {"label": "B", "text": "Microdochectomy", "correct": true}, {"label": "C", "text": "Hadfield procedure", "correct": false}, {"label": "D", "text": "Nipple sparing mastectomy", "correct": false}], "correct_answer": "B. Microdochectomy", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Microdochectomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Macrodochectomy: This is a procedure where a larger segment of the ductal system in the breast is removed , not specifically for isolated discharging ducts.</li><li>• Option A. Macrodochectomy:</li><li>• procedure where a larger segment of the ductal system in the breast is removed</li><li>• Option C. Hadfield procedure: This procedure is typically used for the management of chronic breast abscess or duct ectasia and involves the removal of all major ducts beneath the nipple .</li><li>• Option C. Hadfield procedure:</li><li>• used for the management of chronic breast abscess</li><li>• duct ectasia</li><li>• removal of all major ducts beneath the nipple</li><li>• Option D. Nipple Sparing Mastectomy: In this procedure, the breast tissue is removed while preserving the nipple and areola . It is a type of mastectomy for breast cancer treatment, not indicated for isolated duct issues.</li><li>• Option D. Nipple Sparing Mastectomy:</li><li>• breast tissue is removed while preserving the nipple and areola</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Microdochectomy is the surgical removal of a problematic lactiferous duct causing pathological nipple discharge , intended to resolve the discharge and exclude underlying pathology . It is typically done for intra-ductal papilloma.</li><li>➤ Microdochectomy</li><li>➤ surgical removal of a problematic lactiferous duct</li><li>➤ pathological nipple discharge</li><li>➤ intended to resolve</li><li>➤ discharge</li><li>➤ exclude underlying pathology</li><li>➤ intra-ductal papilloma.</li><li>➤ A probe or a stiff nylon suture is inserted into the duct from which the discharge is emerging . A tennis racket incision can be made to encompass the entire duct or a Peri areolar incision is used and the nipple flap dissected to reach the duct . The duct is then excised.</li><li>➤ probe or a stiff nylon suture</li><li>➤ inserted into the duct from which the discharge is emerging</li><li>➤ tennis racket incision</li><li>➤ encompass the entire duct or a Peri areolar incision</li><li>➤ nipple flap dissected to reach the duct</li><li>➤ Ref : Online resource http://www.jcrp.org.tw/pic/paper/166/publishfile.pdf</li><li>➤ Ref</li><li>➤ : Online resource</li><li>➤ http://www.jcrp.org.tw/pic/paper/166/publishfile.pdf</li><li>➤ Bailey &amp; love’s short practice of surgery -27 th edition page no 865</li><li>➤ Bailey &amp; love’s short practice of surgery -27 th edition page no 865</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Bilateral, multicentric type of lesions are usually seen in:", "options": [{"label": "A", "text": "Ductal carcinoma in situ (DCIS)", "correct": false}, {"label": "B", "text": "Lobular carcinoma in situ (LCIS)", "correct": true}, {"label": "C", "text": "Giant fibroadenoma", "correct": false}, {"label": "D", "text": "Galactocele", "correct": false}], "correct_answer": "B. Lobular carcinoma in situ (LCIS)", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/22/whatsapp-image-2024-03-22-at-115355-am-2.jpeg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-191938.png"], "explanation": "<p><strong>Ans. B) Lobular carcinoma in situ (LICIS) is usually multicentric and bilateral.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Ductal Carcinoma In Situ - DCIS: DCIS is usually unilateral and solitary , but can present as multifocal (within the same quadrant) of the breast but is less commonly multicentric (multiple quadrants) or bilateral.</li><li>• Option A. Ductal Carcinoma In Situ - DCIS:</li><li>• unilateral and solitary</li><li>• Option C. Giant Fibroadenoma: This is a benign tumor that usually presents as a single, well-circumscribed mass , and it is neither typically multicentric nor bilateral.</li><li>• Option C. Giant Fibroadenoma:</li><li>• presents as a single, well-circumscribed mass</li><li>• Option D. Galactocele: A milk-filled cyst that occurs postpartum , not typically associated with multicentric or bilateral lesions.</li><li>• Option D. Galactocele:</li><li>• milk-filled cyst that occurs postpartum</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Lobular carcinoma in situ (LCIS) commonly presents as multicentric and bilateral lesions , which requires a careful evaluation of both breasts , while ductal carcinoma in situ (DCIS) is more likely to be multifocal within the same quadrant .</li><li>➤ Lobular carcinoma in situ</li><li>➤ presents as multicentric and bilateral lesions</li><li>➤ careful evaluation of both breasts</li><li>➤ ductal carcinoma in situ</li><li>➤ multifocal within the same quadrant</li><li>➤ Multicentricity : occurrence of a second breast cancer outside the breast quadrant of the primary cancer (or at least 4 cm away). Multifocality : occurrence of a second cancer within the same breast quadrant as the primary cancer (or within 4 cm of it).</li><li>➤ Multicentricity : occurrence of a second breast cancer outside the breast quadrant of the primary cancer (or at least 4 cm away).</li><li>➤ Multicentricity</li><li>➤ Multifocality : occurrence of a second cancer within the same breast quadrant as the primary cancer (or within 4 cm of it).</li><li>➤ Multifocality</li><li>➤ Characteristic of in situ ductal (DCIS) and lobular (LCIS) carcinoma of the breast</li><li>➤ Characteristic of in situ ductal (DCIS) and lobular (LCIS) carcinoma of the breast</li><li>➤ Ref : Schwartz’s principles of surgery -10 th edition page no 519</li><li>➤ Ref</li><li>➤ : Schwartz’s principles of surgery -10 th edition page no 519</li><li>➤ Online resource https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5841603/</li><li>➤ Online resource</li><li>➤ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5841603/</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Consider following statements about Paget’s disease of breast: It is an in-situ cancer Presence of Paget cells is needed for diagnosis. Underlying carcinoma is usually LCIS. Treatment is mastectomy or wide local excision. Which of the above are true statements?", "options": [{"label": "A", "text": "1,2,3,4", "correct": false}, {"label": "B", "text": "1,2, and 4", "correct": true}, {"label": "C", "text": "1,2, and 3", "correct": false}, {"label": "D", "text": "1,3, and 4", "correct": false}], "correct_answer": "B. 1,2, and 4", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) 1,2, and 4.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Paget’s disease is usually associated with underlying ductal carcinoma in situ (DCIS).</li><li>• Paget’s disease</li><li>• underlying ductal carcinoma in situ</li><li>• Paget’s disease is a superficial manifestation of an underlying breast carcinoma . It accounts for 1% or less of breast malignancies.</li><li>• Paget’s disease</li><li>• superficial manifestation</li><li>• underlying breast carcinoma</li><li>• Clinical features:</li><li>• Clinical features:</li><li>• Presents a chronic, eczematous eruption of the nipple and progresses to an ulcerated, weeping lesion. Usually is associated with extensive DCIS and may be associated with an invasive cancer that may metastasize to axillary lymph nodes. A palpable mass may or may not be present.</li><li>• Presents a chronic, eczematous eruption of the nipple and progresses to an ulcerated, weeping lesion.</li><li>• Usually is associated with extensive DCIS and may be associated with an invasive cancer that may metastasize to axillary lymph nodes.</li><li>• A palpable mass may or may not be present.</li><li>• Diagnosis:</li><li>• Diagnosis:</li><li>• A nipple biopsy specimen will show a population of cells that are identical to the underlying DCIS cells (pagetoid features or pagetoid change). Paget cells are pathognomonic - Large, pale, vacuolated cells in the rete pegs of the epithelium.</li><li>• nipple biopsy specimen</li><li>• population of cells that are identical to the underlying DCIS cells</li><li>• Paget cells are pathognomonic</li><li>• Large, pale, vacuolated cells in the rete pegs of the epithelium.</li><li>• Treatment:</li><li>• Treatment:</li><li>• Treatment depends on the status of the underlying carcinoma. Paget’s disease without associated underlying malignancy is treated by central core excision, removing a cone of major milk ducts along with the nipple and areola down to the P. major muscle, followed by radiotherapy.</li><li>• Paget’s disease with underlying malignancy is treated by mastectomy and evaluation of the axillary nodal status .</li><li>• Paget’s disease</li><li>• malignancy is treated by mastectomy and evaluation of the axillary nodal status</li><li>• Differential diagnosis:</li><li>• Differential diagnosis:</li><li>• Eczema Contact dermatitis Post radiation dermatitis Superficial spreading melanoma Differentiated by the presence of S-100 antigen immunostaining in melanoma in contrast to carcinoembryonic antigen (CEA) immunostaining in Paget’s.</li><li>• Eczema</li><li>• Contact dermatitis</li><li>• Post radiation dermatitis</li><li>• Superficial spreading melanoma</li><li>• Differentiated by the presence of S-100 antigen immunostaining in melanoma in contrast to carcinoembryonic antigen (CEA) immunostaining in Paget’s.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Paget's disease of the breast is an in situ cancer that requires the presence of Paget cells for diagnosis and is usually associated with an underlying ductal carcinoma , not lobular . Treatment often involves mastectomy or wide local excision depending on the extent of the underlying disease.</li><li>➤ Paget's disease</li><li>➤ breast is an in situ cancer</li><li>➤ presence of Paget cells</li><li>➤ associated with an underlying ductal carcinoma</li><li>➤ not lobular</li><li>➤ Ref : Schwartz’s principles of surgery -10 th edition page no 521</li><li>➤ Ref</li><li>➤ : Schwartz’s principles of surgery -10 th edition page no 521</li><li>➤ Sabiston textbook of surgery 20 th edition page no 883</li><li>➤ Sabiston textbook of surgery 20 th edition page no 883</li><li>➤ Bailey &amp; love’s short practice of surgery -28 th edition page no 924</li><li>➤ Bailey &amp; love’s short practice of surgery -28 th edition page no 924</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "The van Nuys grading system for ductal carcinoma in situ does not include:", "options": [{"label": "A", "text": "Hormone receptor ER/PR status", "correct": true}, {"label": "B", "text": "Size of lesion", "correct": false}, {"label": "C", "text": "Age of patient", "correct": false}, {"label": "D", "text": "Distance from margin (tumor free margin)", "correct": false}], "correct_answer": "A. Hormone receptor ER/PR status", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-192441.png"], "explanation": "<p><strong>Ans. A) Hormone receptor</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Staining for estrogen and progesterone receptors is not part of the Van Nuys system .</li><li>• Staining for estrogen</li><li>• progesterone receptors is not part of the Van Nuys system</li><li>• The components of the van Nuys Prognostic Index (VNPI) for grading ductal carcinoma in situ (DCIS) are as follows:</li><li>• components of the van Nuys Prognostic Index</li><li>• grading ductal carcinoma in situ</li><li>• Patient’s age Type of DCIS (histologic variant based on nuclear grade and presence of necrosis) Presence of microcalcification Extent of resection margin/Distance from margin Size of tumor</li><li>• Patient’s age</li><li>• Type of DCIS (histologic variant based on nuclear grade and presence of necrosis)</li><li>• Presence of microcalcification</li><li>• Extent of resection margin/Distance from margin</li><li>• Size of tumor</li><li>• Patients with a high score in this grading system benefit from radiotherapy after excision , whereas from radiotherapy after excision , whereas those with low-grade tumors , whose tumor is completely excised , need no further treatment.</li><li>• Patients with a high score in this grading system</li><li>• radiotherapy after excision</li><li>• radiotherapy after excision</li><li>• low-grade tumors</li><li>• tumor is completely excised</li><li>• A score, ranging from 1 for lesions with the best prognosis to 3 for lesions with the worst prognostic predictors . Scores range from 4 (least likely to recur) to 12 (most likely to recur).</li><li>• score, ranging from 1 for lesions with the best prognosis to 3 for lesions with the worst prognostic predictors</li><li>• Note: The type of microcalcification seen on imaging, helps in determining the nuclear grade of DCIS.</li><li>• Note: The type of microcalcification seen on imaging, helps in determining the nuclear grade of DCIS.</li><li>• Linear branching type of microcalcification is associated with high nuclear grade. Fine granular type of microcalcification is associated with low nuclear grade.</li><li>• Linear branching type of microcalcification is associated with high nuclear grade.</li><li>• Fine granular type of microcalcification is associated with low nuclear grade.</li><li>• Ref : Bailey &amp; love’s short practice of surgery -27 th edition Pg 872</li><li>• Ref : Bailey &amp; love’s short practice of surgery -27 th edition Pg 872</li><li>• Sabiston textbook of surgery 20 th edition page no 853</li><li>• Sabiston textbook of surgery 20 th edition page no 853</li><li>• Online resource http://www.archintsurg.org/text.asp?2016/6/3/137/202366</li><li>• Online resource http://www.archintsurg.org/text.asp?2016/6/3/137/202366</li><li>• Online resource https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4132440/</li><li>• Online resource https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4132440/</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following statements regarding breast carcinoma is false?", "options": [{"label": "A", "text": "Mucinous carcinomas are usually hormone negative.", "correct": true}, {"label": "B", "text": "Cutaneous edema in inflammatory carcinoma is the result of blockage of the subdermal lymphatics with carcinoma cells.", "correct": false}, {"label": "C", "text": "Calcifications frequently are associated with ductal carcinoma in situ.", "correct": false}, {"label": "D", "text": "Lobular carcinoma in situ is multifocal and bilateral.", "correct": false}], "correct_answer": "A. Mucinous carcinomas are usually hormone negative.", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Mucinous carcinomas are usually hormone negative.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. Inflammatory Carcinoma: Correct . Inflammatory breast carcinoma is characterized by cutaneous edema, commonly known as peau d'orange, due to lymphatic obstruction by cancer cells.</li><li>• Option B. Inflammatory Carcinoma:</li><li>• Correct</li><li>• Option C. Ductal Carcinoma In Situ: Correct . Calcifications are often associated with ductal carcinoma in situ and are frequently detected on mammography as the earliest sign of this type of breast cancer.</li><li>• Option C. Ductal Carcinoma In Situ:</li><li>• Correct</li><li>• Option D. Lobular Carcinoma In Situ: Correct . LCIS is known for being multifocal (multiple tumors within the same quadrant) and bilateral (occurring in both breasts).</li><li>• Option D. Lobular Carcinoma In Situ:</li><li>• Correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Mucinous carcinomas of the breast are typically hormone receptor-positive , which influences treatment options and generally carries a favourable prognosis .</li><li>➤ Mucinous carcinomas</li><li>➤ breast</li><li>➤ hormone receptor-positive</li><li>➤ influences treatment options</li><li>➤ carries a favourable prognosis</li><li>➤ Mucinous carcinomas are usually hormone-positive . They are also called colloid carcinoma. It is a low-grade tumour with good prognosis and is typically seen in the elderly, presenting as a bulky mass.</li><li>➤ Mucinous carcinomas</li><li>➤ hormone-positive</li><li>➤ colloid carcinoma.</li><li>➤ low-grade tumour with good prognosis</li><li>➤ elderly, presenting as a bulky mass.</li><li>➤ Ref : Bailey &amp; love’s short practice of surgery -27 th edition page no 872</li><li>➤ Ref</li><li>➤ : Bailey &amp; love’s short practice of surgery -27 th edition page no 872</li><li>➤ Online resource https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4428244/</li><li>➤ Online resource</li><li>➤ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4428244/</li><li>➤ Refer link https://academic.oup.com/ajcp/article/146/suppl_1/314/2246854</li><li>➤ Refer link</li><li>➤ https://academic.oup.com/ajcp/article/146/suppl_1/314/2246854</li><li>➤ Schwartz’s principles of surgery- 10th edition page no:520</li><li>➤ Schwartz’s principles of surgery- 10th edition page no:520</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Positive predictive value of triple assessment for breast cancer:", "options": [{"label": "A", "text": "85%", "correct": false}, {"label": "B", "text": "95%", "correct": false}, {"label": "C", "text": "99%", "correct": false}, {"label": "D", "text": "99.9%", "correct": true}], "correct_answer": "D. 99.9%", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-192933.png"], "explanation": "<p><strong>Ans. D) 99.9%</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Patients presenting with a breast lump, nipple discharge or other symptoms are assessed by a combination of clinical examination (including history), radiological imaging and tissue sampling taken for either cytological or histological analysis. This combined approach is called ‘triple assessment’ . The positive predictive value and diagnostic accuracy of this combination approach is 100%.</li><li>• breast lump, nipple discharge</li><li>• combined approach is called ‘triple assessment’</li><li>• Ref : Bailey 28 th Edition fig 58.2.</li><li>• Ref</li><li>• : Bailey 28 th Edition fig 58.2.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of the following features in mammography suggest malignancy except:", "options": [{"label": "A", "text": "Spiculations", "correct": false}, {"label": "B", "text": "III-defined margins", "correct": false}, {"label": "C", "text": "Macrocalcification", "correct": true}, {"label": "D", "text": "Irregular mass", "correct": false}], "correct_answer": "C. Macrocalcification", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-193304.png", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-193350.png"], "explanation": "<p><strong>Ans. C) Macrocalcification</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Spiculations: Spiculations are radiographic features that resemble spikes radiating from a mass and are highly suggestive of malignancy due to the invasive nature of certain cancers.</li><li>• Option A. Spiculations:</li><li>• radiographic features that resemble spikes radiating from a mass</li><li>• malignancy</li><li>• Option B. Ill-defined Margins: Cancers often have irregular , poorly defined edges on mammograms , which can indicate an aggressive growth pattern that does not respect normal tissue boundaries.</li><li>• Option B. Ill-defined Margins:</li><li>• Cancers often have irregular</li><li>• poorly defined edges</li><li>• mammograms</li><li>• aggressive growth pattern</li><li>• Option D. (Irregular Mass): An irregularly shaped mass on a mammogram is concerning for malignancy due to its non-uniform appearance , as benign masses are more likely to be round and well-circumscribed.</li><li>• Option D. (Irregular Mass):</li><li>• irregularly shaped mass on a mammogram</li><li>• malignancy due to its non-uniform appearance</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In mammography , features that raise suspicion for breast cancer include spiculations , ill-defined margins , and irregular masses , while macrocalcifications are generally associated with benign breast conditions .</li><li>➤ mammography</li><li>➤ raise suspicion for breast cancer include spiculations</li><li>➤ ill-defined margins</li><li>➤ irregular masses</li><li>➤ macrocalcifications</li><li>➤ benign breast conditions</li><li>➤ Microcalcification (&lt;0.5 mm in diameter) in mammography is suggestive of malignancy .</li><li>➤ Microcalcification</li><li>➤ mammography</li><li>➤ malignancy</li><li>➤ Table: Mammographic appearance of benign and malignant masses</li><li>➤ Table: Mammographic appearance of benign and malignant masses</li><li>➤ Following is the sequence of malignancy in decreasing order ie. from highest risk to the least risk:</li><li>➤ Cluster microcalcification (maximum risk) Linear microcalcification Segmental micro calcification Diffuse microcalcification (minimum risk)</li><li>➤ Cluster microcalcification (maximum risk)</li><li>➤ Linear microcalcification</li><li>➤ Segmental micro calcification</li><li>➤ Diffuse microcalcification (minimum risk)</li><li>➤ Ref : Grainger &amp; Allison’s Diagnostic Radiology 6 th edition page nos. 1679 and 1674</li><li>➤ Ref</li><li>➤ : Grainger &amp; Allison’s Diagnostic Radiology 6 th edition page nos. 1679 and 1674</li><li>➤ Schwartz’s principle of surgery -10 th edition page no. 509</li><li>➤ Schwartz’s principle of surgery -10 th edition page no. 509</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "The likelihood of a lesion on a mammogram being carcinomatous is 40%. The radiologist will report it as what BIRADS grade?", "options": [{"label": "A", "text": "4b", "correct": true}, {"label": "B", "text": "4c", "correct": false}, {"label": "C", "text": "3", "correct": false}, {"label": "D", "text": "4a", "correct": false}], "correct_answer": "A. 4b", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-193623.png"], "explanation": "<p><strong>Ans. A) 4b</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• For a lesion having 40% likelihood of being carcinomatous, the breast imaging reporting and system (BIRADS) category/grade is 4b.</li><li>• For a lesion having 40% likelihood of being carcinomatous, the breast imaging reporting and system (BIRADS) category/grade is 4b.</li><li>• “In the UK , all women aged between 50 and 70 years are invited for mammographic screening every 3 years . In low- and middle-income countries, population-based mammographic screening is not available.</li><li>• UK</li><li>• women aged between 50 and 70 years</li><li>• mammographic screening every 3 years</li><li>• In some Asian countries, clinical breast examination by a trained healthcare professional along with increasing breast health awareness by breast self-examination is being encouraged as a mode of screening. In India, national screening involves multi disease screening for cancer of the mouth, breast and cervix for all women aged 30–65 years”</li><li>• Ref : Bailey 28 th Ed pg 943.</li><li>• Ref</li><li>• : Bailey 28 th Ed pg 943.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old woman is planned for breast conservation surgery for T2N1M0 cancer of size 4.5 cm. The patient is inquiring regarding the need for breast reconstruction after wide local excision is done. For a woman with average size breasts, what proportion of breast can be excised, without the need for oncoplastic reconstruction?", "options": [{"label": "A", "text": "10%", "correct": false}, {"label": "B", "text": "20%", "correct": true}, {"label": "C", "text": "25%", "correct": false}, {"label": "D", "text": "30%", "correct": false}], "correct_answer": "B. 20%", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/21/screenshot-2024-03-21-095738.png"], "explanation": "<p><strong>Ans. B) 20%.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Wide local excision (WLE) of up to 20% of the breast volume can be achieved by excision of the tumour with adequate margins and closure of the defect by approximation of the breast tissue with absorbable sutures. Volume loss greater than 20% or an unfavourable breast-to-tumour ratio requires an oncoplastic procedure to fill the defect so created by mobilising the breast tissue. Oncoplasty is defined as tumour excision with wide margins followed by repair of the defect by local rearrangement / replacement of the breast tissue and the nipple–areola complex to maintain shape and symmetry. This may be achieved by volume displacement (level 1) or by volume replacement using a distant or local fap (level 2)</li><li>• Wide local excision (WLE) of up to 20% of the breast volume can be achieved by excision of the tumour with adequate margins and closure of the defect by approximation of the breast tissue with absorbable sutures.</li><li>• Wide local excision</li><li>• up to 20%</li><li>• breast volume can be achieved by excision of the tumour</li><li>• adequate margins</li><li>• closure of the defect</li><li>• Volume loss greater than 20% or an unfavourable breast-to-tumour ratio requires an oncoplastic procedure to fill the defect so created by mobilising the breast tissue.</li><li>• Volume loss greater than 20%</li><li>• unfavourable breast-to-tumour ratio</li><li>• oncoplastic procedure to fill the defect</li><li>• Oncoplasty is defined as tumour excision with wide margins followed by repair of the defect by local rearrangement / replacement of the breast tissue and the nipple–areola complex to maintain shape and symmetry.</li><li>• Oncoplasty</li><li>• tumour excision with wide margins</li><li>• repair of the defect by local rearrangement</li><li>• This may be achieved by volume displacement (level 1) or by volume replacement using a distant or local fap (level 2)</li><li>• volume displacement</li><li>• volume replacement</li><li>• distant or local fap</li><li>• Ref : Bailey 28 th Ed Pg 935, 937.</li><li>• Ref</li><li>• : Bailey 28 th Ed Pg 935, 937.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the radiographic modality that you will use to assess a patient’s breast containing silicone implants:", "options": [{"label": "A", "text": "Mammography", "correct": false}, {"label": "B", "text": "USG", "correct": false}, {"label": "C", "text": "MRI", "correct": true}, {"label": "D", "text": "CT", "correct": false}], "correct_answer": "C. MRI", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) MRI</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Mammography: While mammography is the standard imaging modality for breast cancer screening , it has limitations in evaluating breasts with silicone implants, as the implants can obscure visualization of the breast tissue.</li><li>• Option A. Mammography:</li><li>• mammography</li><li>• standard imaging modality for breast cancer screening</li><li>• Option B (USG): Ultrasound may help in evaluating certain areas of the breast and can be useful in distinguishing between fluid-filled cysts and solid masses , but it does not provide as comprehensive an assessment as MRI, especially in the presence of implants.</li><li>• Option B (USG):</li><li>• Ultrasound</li><li>• evaluating certain areas of the breast</li><li>• can be useful in distinguishing between fluid-filled cysts and solid masses</li><li>• Option D (CT): Computed tomography (CT) is not typically used for routine breast imaging due to its lower sensitivity for detecting small breast cancers and because it exposes the patient to a higher dose of radiation compared to mammography.</li><li>• Option D (CT):</li><li>• Computed tomography</li><li>• not typically used for routine breast imaging due to its lower sensitivity for detecting small breast cancers</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ Magnetic resonance imaging (MRI) is the best imaging modality for the breasts of women with implants.</li><li>➤ Magnetic resonance imaging</li><li>➤ best imaging modality</li><li>➤ breasts of women with implants.</li><li>➤ MRI of the breast is also used in:</li><li>➤ Screening of individuals with a positive family history/high risk of breast cancer . Assessing loco-regional spread (multifocality and multicentricity) of carcinoma Differentiating scar form recurrence in women who have received breast conservation therapy.</li><li>➤ Screening of individuals with a positive family history/high risk of breast cancer .</li><li>➤ Screening of individuals</li><li>➤ positive family history/high risk of breast cancer</li><li>➤ Assessing loco-regional spread (multifocality and multicentricity) of carcinoma</li><li>➤ Differentiating scar form recurrence in women who have received breast conservation therapy.</li><li>➤ Ref : Bailey and love’s short practice of surgery -28th edition page no 916-917</li><li>➤ Ref</li><li>➤ : Bailey and love’s short practice of surgery -28th edition page no 916-917</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following histopathological modalities is the best to confirm the diagnosis of breast carcinoma?", "options": [{"label": "A", "text": "Imprint cytology", "correct": false}, {"label": "B", "text": "Sentinel LN biopsy", "correct": false}, {"label": "C", "text": "Fine-needle aspiration cytology", "correct": false}, {"label": "D", "text": "Tru Cut biopsy", "correct": true}], "correct_answer": "D. Tru Cut biopsy", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Tru Cut biopsy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A (Imprint Cytology): This technique involves pressing a tissue sample onto a glass slide to transfer cells, which are then stained and examined under a microscope . While it can provide rapid results, it is not as definitive as a core-needle biopsy because it does not preserve tissue architecture.</li><li>• Option A (Imprint Cytology):</li><li>• pressing a tissue sample onto a glass slide to transfer cells,</li><li>• stained and examined under a microscope</li><li>• Option B (Sentinel Lymph Node Biopsy): This procedure is used to determine the spread of breast cancer by examining the first lymph node (s) to which cancer cells are likely to spread from the primary tumor. It is not used for the initial diagnosis of breast cancer.</li><li>• Option B (Sentinel Lymph Node Biopsy):</li><li>• determine the spread of breast cancer by examining the first lymph node</li><li>• Option C (Fine-Needle Aspiration Cytology - FNAC): FNAC uses a thin needle to extract cells from a breast lump . It is less invasive than a core biopsy and can quickly suggest a diagnosis, but it may not be as definitive, particularly for distinguishing between in situ and invasive carcinomas.</li><li>• Option C (Fine-Needle Aspiration Cytology - FNAC):</li><li>• thin needle to extract cells from a breast lump</li><li>• less invasive</li><li>• core biopsy</li><li>• Fine-needle aspiration cytology (FNAC) is a cytological investigation done using a 22-30G needle and is not the investigation of choice. FNAC cannot determine if a tumor is invasive or in situ. It is, however, the initial investigation in many cases. Image-guided biopsy is used only in the case of non-palpable lesions.</li><li>• Fine-needle aspiration cytology (FNAC) is a cytological investigation done using a 22-30G needle and is not the investigation of choice. FNAC cannot determine if a tumor is invasive or in situ. It is, however, the initial investigation in many cases.</li><li>• Image-guided biopsy is used only in the case of non-palpable lesions.</li><li>• Ref : Schwartz principle of surgery -9 th edition page no 529, Bailey 28 th Ed pg 918.</li><li>• Ref</li><li>• : Schwartz principle of surgery -9 th edition page no 529, Bailey 28 th Ed pg 918.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 37-year-old unmarried female, nulliparous having regular sexual intercourse, on OCPs since last 3 years, gives the history that her mother had carcinoma breast at 50 years of age and sister had ovarian cancer at 40 years of age. What will you advise as the next step?", "options": [{"label": "A", "text": "Stop taking OCP", "correct": false}, {"label": "B", "text": "DO mammography annually", "correct": false}, {"label": "C", "text": "Genetic counseling &amp; BRCA testing", "correct": true}, {"label": "D", "text": "Immediate prophylactic mastectomy", "correct": false}], "correct_answer": "C. Genetic counseling & BRCA testing", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Genetic counseling and BRCA testing</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A. Stop taking OCP: Oral contraceptive pills (OCPs) have been associated with a slightly increased risk of breast cancer , but they also offer protective effects against ovarian cancer . The decision to stop OCPs should be individualized based on a detailed risk assessment.</li><li>• Option A. Stop taking OCP:</li><li>• associated with a slightly increased risk of breast cancer</li><li>• offer protective effects against ovarian cancer</li><li>• Option B. Do Mammography Annually: While annual mammography is important for breast cancer screening , starting annual mammograms at 37 without other indications might not be necessary, and it does not address her genetic risk.</li><li>• Option B. Do Mammography Annually:</li><li>• important for breast cancer screening</li><li>• starting annual mammograms at 37</li><li>• Option D. Immediate Prophylactic Mastectomy: Prophylactic mastectomy may be considered for those with a confirmed high genetic risk (BRCA positive), but it is not the immediate next step before genetic risk is assessed.</li><li>• Option D. Immediate Prophylactic Mastectomy:</li><li>• considered for those with a confirmed high genetic risk</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ For a patient with a family history of breast and ovarian cancer , the next step is genetic counseling and BRCA testing to assess hereditary cancer risk and guide further preventive measures, rather than immediate prophylactic surgery or alteration of contraceptive practices.</li><li>➤ family history of breast and ovarian cancer</li><li>➤ next step is genetic counseling</li><li>➤ BRCA testing to assess hereditary cancer risk</li><li>➤ Indications for genetic risk evaluation</li><li>➤ Indications for genetic risk evaluation</li><li>➤ An individual at any age with a known pathogenic/likely pathogenic variant in a cancer susceptibility gene within the family Breast cancer diagnosed age ≤50 years TNBC diagnosed age ≤60 years Two breast cancer primaries Breast cancer at any age with one or more relative with breast cancer diagnosed ≤50 years, invasive ovarian cancer, male breast cancer, pancreatic cancer, high-grade or metastatic prostate cancer Breast cancer at any age with two or more affected relatives Male breast cancer</li><li>➤ An individual at any age with a known pathogenic/likely pathogenic variant in a cancer susceptibility gene within the family</li><li>➤ Breast cancer diagnosed age ≤50 years</li><li>➤ TNBC diagnosed age ≤60 years</li><li>➤ Two breast cancer primaries</li><li>➤ Breast cancer at any age with one or more relative with breast cancer diagnosed ≤50 years, invasive ovarian cancer, male breast cancer, pancreatic cancer, high-grade or metastatic prostate cancer</li><li>➤ Breast cancer at any age with two or more affected relatives</li><li>➤ Male breast cancer</li><li>➤ Ref : Bailey 28 th Ed. Summary box 58.5</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Summary box 58.5</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of these are components in management of cyclical mastalgia in women suffering from ANDI breast except:", "options": [{"label": "A", "text": "Oil of evening primrose", "correct": false}, {"label": "B", "text": "Danazol", "correct": false}, {"label": "C", "text": "Tamoxifen", "correct": false}, {"label": "D", "text": "Lumpectomy", "correct": true}], "correct_answer": "D. Lumpectomy", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Lumpectomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Oil of Evening Primrose: Evening primrose oil is rich in gamma-linolenic acid and is used as a dietary supplement to manage the symptoms of cyclical mastalgia .</li><li>• Option A. Oil of Evening Primrose:</li><li>• rich in gamma-linolenic acid</li><li>• used as a dietary supplement</li><li>• cyclical mastalgia</li><li>• Option B. Danazol: Danazol is a synthetic steroid that alters the hormonal milieu and is often used in the treatment of severe mastalgia . It's an effective, though less commonly used treatment due to its side effect profile.</li><li>• Option B. Danazol:</li><li>• synthetic steroid that alters the hormonal milieu and is often used in the treatment of severe mastalgia</li><li>• Option C. Tamoxifen: Tamoxifen is a selective estrogen receptor modulator used in the management of breast pain , particularly when it's severe or resistant to other treatments.</li><li>• Option C. Tamoxifen:</li><li>• selective estrogen receptor modulator</li><li>• management of breast pain</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ For women suffering from cyclical mastalgia due to ANDI (aberrations of normal development and involution), management typically includes supportive measures and medications such as evening primrose oil , tamoxifen , or danazol . Lumpectomy is not a component of managing cyclical mastalgia as it is a surgical intervention reserved for the removal of lumps with potential or confirmed malignancy.</li><li>➤ women suffering from cyclical mastalgia due to ANDI</li><li>➤ management typically includes supportive measures and medications such as evening primrose oil</li><li>➤ tamoxifen</li><li>➤ danazol</li><li>➤ Management of Mastalgia:</li><li>➤ Management of Mastalgia:</li><li>➤ Reassure adequate support Tight sports brassiere during the day Use a VAS breast pain chart to record severity Consider medication Flax seeds or Oil of evening primrose Topical NSAID cream (diclofenac or piroxicam)- Useful in mild to moderate mastalgia Consider systemic medication if pain score &gt;3 on a VAS of 0-10 Tamoxifen 10 mg daily For 3–6 months Danazol 50–300 mg daily For 3–6 months Meloxifene 30 mg twice For 3–6 months used in both cyclical a week and non-cyclical mastalgia and for treating nodularity LHRH agonist of Short duration: use for 3 months with anti estrogen: recalcitrant pain not relieved by the tamoxifen or raloxifene.</li><li>➤ Reassure adequate support</li><li>➤ Tight sports brassiere during the day</li><li>➤ Use a VAS breast pain chart to record severity</li><li>➤ Consider medication Flax seeds or Oil of evening primrose Topical NSAID cream (diclofenac or piroxicam)- Useful in mild to moderate mastalgia Consider systemic medication if pain score &gt;3 on a VAS of 0-10 Tamoxifen 10 mg daily For 3–6 months Danazol 50–300 mg daily For 3–6 months Meloxifene 30 mg twice For 3–6 months used in both cyclical a week and non-cyclical mastalgia and for treating nodularity LHRH agonist of Short duration: use for 3 months with anti estrogen: recalcitrant pain not relieved by the tamoxifen or raloxifene.</li><li>➤ Flax seeds or Oil of evening primrose Topical NSAID cream (diclofenac or piroxicam)- Useful in mild to moderate mastalgia Consider systemic medication if pain score &gt;3 on a VAS of 0-10 Tamoxifen 10 mg daily For 3–6 months Danazol 50–300 mg daily For 3–6 months Meloxifene 30 mg twice For 3–6 months used in both cyclical a week and non-cyclical mastalgia and for treating nodularity LHRH agonist of Short duration: use for 3 months with anti estrogen: recalcitrant pain not relieved by the tamoxifen or raloxifene.</li><li>➤ Flax seeds or Oil of evening primrose</li><li>➤ Topical NSAID cream (diclofenac or piroxicam)- Useful in mild to moderate mastalgia</li><li>➤ Consider systemic medication if pain score &gt;3 on a VAS of 0-10</li><li>➤ Tamoxifen 10 mg daily For 3–6 months</li><li>➤ Danazol 50–300 mg daily For 3–6 months</li><li>➤ Meloxifene 30 mg twice For 3–6 months used in both cyclical a week and non-cyclical mastalgia and for treating nodularity</li><li>➤ LHRH agonist of Short duration: use for 3 months with anti estrogen: recalcitrant pain not relieved by the tamoxifen or raloxifene.</li><li>➤ Ref : Bailey 28 th E. table 58.2</li><li>➤ Ref</li><li>➤ : Bailey 28 th E. table 58.2</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "2 days post total thyroidectomy, patient complains of peri-oral tingling. What would be the next step?", "options": [{"label": "A", "text": "Wound exploration", "correct": false}, {"label": "B", "text": "Indirect laryngoscopy for vocal palsy", "correct": false}, {"label": "C", "text": "Serum calcium level", "correct": true}, {"label": "D", "text": "Serum TSH, free T3 and T4 level", "correct": false}], "correct_answer": "C. Serum calcium level", "question_images": [], "explanation_images": [], "explanation": "<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these manoeuvres will prevent post op hypoparathyroidism in thyroidectomy (STA= Superior thyroid artery, ITA= Inferior thyroid artery)?", "options": [{"label": "A", "text": "Ligation of ITA away from the gland", "correct": false}, {"label": "B", "text": "Ligation of STA away from the gland", "correct": false}, {"label": "C", "text": "Ligation of ITA close to the gland", "correct": true}, {"label": "D", "text": "Ligation of STA close to the gland", "correct": false}], "correct_answer": "C. Ligation of ITA close to the gland", "question_images": [], "explanation_images": [], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference</li><li>↳ Schwartz’s principle of surgery 10 th edition, pages 1553-1554</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "After total thyroidectomy, in post-operative recovery room, patient experienced acute breathlessness and cyanosis. His O2 saturation dropped to 85%. What is the next step?", "options": [{"label": "A", "text": "Emergency cricothyrotomy", "correct": false}, {"label": "B", "text": "Emergency tracheostomy", "correct": false}, {"label": "C", "text": "Shift to OT and remove sutures of wound", "correct": true}, {"label": "D", "text": "Needle thoracotomy in triangle of safety", "correct": false}], "correct_answer": "C. Shift to OT and remove sutures of wound", "question_images": [], "explanation_images": [], "explanation": "<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "AGES, AMES, MACIS are all prognostic indicators of which carcinoma?", "options": [{"label": "A", "text": "Thyroid", "correct": true}, {"label": "B", "text": "Prostate", "correct": false}, {"label": "C", "text": "Gastric", "correct": false}, {"label": "D", "text": "Colorectal", "correct": false}], "correct_answer": "A. Thyroid", "question_images": [], "explanation_images": [], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference:</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A child with a midline swelling in the neck, has to undergo a sistrunk procedure. Along with en bloc cystectomy, what other structures will the surgeon resect?", "options": [{"label": "A", "text": "Thyroglossal tract only", "correct": false}, {"label": "B", "text": "Central part of hyoid bone and thyroglossal tract", "correct": true}, {"label": "C", "text": "Thyroglossal tract and part of thyroid", "correct": false}, {"label": "D", "text": "Thyroglossal tract and associated cervical lymph nodes", "correct": false}], "correct_answer": "B. Central part of hyoid bone and thyroglossal tract", "question_images": [], "explanation_images": [], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference:</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A doctor uses this method to palpate the midline swelling in the neck. Choose the correct option.", "options": [{"label": "A", "text": "Lahey’s method", "correct": false}, {"label": "B", "text": "Crile’s method", "correct": true}, {"label": "C", "text": "Pizzillo method", "correct": false}, {"label": "D", "text": "Kocher’s method", "correct": false}], "correct_answer": "B. Crile’s method", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/26/picture1_ufYFscg.png"], "explanation_images": [], "explanation": "<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 27 year old female underwent an FNAC for a discrete thyroid swelling. The report showed a Thy2 lesion. What is your inference?", "options": [{"label": "A", "text": "Cystic lesion", "correct": false}, {"label": "B", "text": "Follicular lesion", "correct": false}, {"label": "C", "text": "Lesion suspicious of malignancy", "correct": false}, {"label": "D", "text": "Non neoplastic lesion", "correct": true}], "correct_answer": "D. Non neoplastic lesion", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/26/screenshot-2023-04-26-123631_eORTQDr.jpg"], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference:</li><li>↳ Sabiston textbook of surgery 2oth edition, page 898</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient underwent a thyroid radionuclide scan. She consumed I 123 at 7 AM. What is the half life of this drug?", "options": [{"label": "A", "text": "4-6 hours", "correct": false}, {"label": "B", "text": "20-24 hours", "correct": false}, {"label": "C", "text": "12-14 hours", "correct": true}, {"label": "D", "text": "8-10 days", "correct": false}], "correct_answer": "C. 12-14 hours", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/26/screenshot-2023-04-26-123631_mFuR2cs.jpg"], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference:</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Following options are a few statements about retrosternal goiter. Choose the correct statement.", "options": [{"label": "A", "text": "Sternal incision is always required to operate.", "correct": false}, {"label": "B", "text": "Most of the retrosternal goiters can be removed by neck incision", "correct": true}, {"label": "C", "text": "It receives blood supply from the thoracodorsal artery", "correct": false}, {"label": "D", "text": "Operated in all patients regardless of symptoms", "correct": false}], "correct_answer": "B. Most of the retrosternal goiters can be removed by neck incision", "question_images": [], "explanation_images": [], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference:</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "P atients present in your OPD, with the following reports. To which patient will you least likely advise surgery?", "options": [{"label": "A", "text": "A 24 year old woman with FNAC report of Bethesda category 4", "correct": false}, {"label": "B", "text": "A 60 year old man with FNAC report of Thy2", "correct": true}, {"label": "C", "text": "A 15 year old with recurrence of thyroid cyst", "correct": false}, {"label": "D", "text": "A 66 year old man with positive Pemberton’s sign", "correct": false}], "correct_answer": "B. A 60 year old man with FNAC report of Thy2", "question_images": [], "explanation_images": [], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference:</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A surgeon is performing a thyroid surgery. Which of the following points poses the highest risk for recurrent laryngeal nerve injury?", "options": [{"label": "A", "text": "In the TE groove as it forms one part of the Beahrs triangle", "correct": false}, {"label": "B", "text": "At the level of the Berry’s ligament as it enters the larynx", "correct": true}, {"label": "C", "text": "As the nerve loops around the aorta", "correct": false}, {"label": "D", "text": "Under the tubercle of Zuckerlandl on the posterolateral position of the gland", "correct": false}], "correct_answer": "B. At the level of the Berry’s ligament as it enters the larynx", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/26/picture1_2nXhQUx.png"], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference:</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 30 year old female underwent a retro-esophageal goitre resection. She was found to have ptosis and loss of hemifacial sweating. What is your diagnosis?", "options": [{"label": "A", "text": "Horner’s syndrome", "correct": true}, {"label": "B", "text": "Transient hypocalcemia", "correct": false}, {"label": "C", "text": "Recurrent laryngeal nerve injury", "correct": false}, {"label": "D", "text": "Post op hematoma", "correct": false}], "correct_answer": "A. Horner’s syndrome", "question_images": [], "explanation_images": [], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference:</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In which of the following conditions will FNAC not differentiate benign from malignant goitre?", "options": [{"label": "A", "text": "Medullary", "correct": false}, {"label": "B", "text": "Papillary", "correct": false}, {"label": "C", "text": "Anaplastic", "correct": false}, {"label": "D", "text": "Follicular", "correct": true}], "correct_answer": "D. Follicular", "question_images": [], "explanation_images": [], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference:</li><li>↳ Bailey and Love 27 th edition page 818</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 55-year-old hypothyroid female patient presents with a painless, hard anterior neck mass, which progresses over weeks to years associated with dysphagia. On physical examination a hard, woody thyroid gland with fixation to the surrounding tissues was noticed. How will you investigate further?", "options": [{"label": "A", "text": "CECT", "correct": false}, {"label": "B", "text": "FNAC", "correct": false}, {"label": "C", "text": "Open biopsy", "correct": true}, {"label": "D", "text": "RAI scan", "correct": false}], "correct_answer": "C. Open biopsy", "question_images": [], "explanation_images": [], "explanation": "<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these represents lateral aberrant thyroid?", "options": [{"label": "A", "text": "Level V cervical node", "correct": false}, {"label": "B", "text": "Level VI cervical node", "correct": true}, {"label": "C", "text": "Ectopic thyroid in anterior sternocleidomastoid muscle", "correct": false}, {"label": "D", "text": "Mediastinal node", "correct": false}], "correct_answer": "B. Level VI cervical node", "question_images": [], "explanation_images": [], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference:</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which is the most common thyroid malignancy that may be found in iodine deficient (endemic goitre) areas?", "options": [{"label": "A", "text": "Papillary", "correct": false}, {"label": "B", "text": "Anaplastic", "correct": false}, {"label": "C", "text": "Follicular", "correct": true}, {"label": "D", "text": "Medullary", "correct": false}], "correct_answer": "C. Follicular", "question_images": [], "explanation_images": [], "explanation": "<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient presents with a Thy3 lesion on FNAC. He was posted for hemithyroidectomy . HPE shows the following findings. What is your next step of management?", "options": [{"label": "A", "text": "No further intervention", "correct": false}, {"label": "B", "text": "Perform central neck dissection", "correct": false}, {"label": "C", "text": "Perform RAI ablation", "correct": false}, {"label": "D", "text": "Perform a total thyroidectomy", "correct": true}], "correct_answer": "D. Perform a total thyroidectomy", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/26/picture1_6rUC0g5.png"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/26/screenshot-2023-04-26-123631_mRhxAzB.jpg"], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference:</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Radioactive iodine ablation of thyroid is an absolute contraindication in?", "options": [{"label": "A", "text": "Pregnant lady with papillary thyroid cancer", "correct": true}, {"label": "B", "text": "Autonomous toxic nodule after 45 years", "correct": false}, {"label": "C", "text": "In follicular carcinoma of thyroid, after total thyroidectomy", "correct": false}, {"label": "D", "text": "In primary thyrotoxicosis after 45 years", "correct": false}], "correct_answer": "A. Pregnant lady with papillary thyroid cancer", "question_images": [], "explanation_images": [], "explanation": "<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45 year old woman has come to your clinic for a follow up after she underwent a total thyroidectomy 2 months back, for papillary thyroid carcinoma. On doing a whole body iodine scan, the report suggested a positive iodine scan. How will you proceed further in this case?", "options": [{"label": "A", "text": "Perform a re exploration of the thyroid gland", "correct": false}, {"label": "B", "text": "Call her for a bi annual follow up", "correct": false}, {"label": "C", "text": "USG guided FNAC", "correct": false}, {"label": "D", "text": "Radioactive iodine ablation", "correct": true}], "correct_answer": "D. Radioactive iodine ablation", "question_images": [], "explanation_images": [], "explanation": "<p><strong>References:</strong></p><ul><li>↳ References:</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "External low dose neck radiation predisposes to which kind of cancer most commonly?", "options": [{"label": "A", "text": "Anaplastic carcinoma of thyroid", "correct": false}, {"label": "B", "text": "Medullary carcinoma of thyroid", "correct": false}, {"label": "C", "text": "Papillary carcinoma of thyroid", "correct": true}, {"label": "D", "text": "Thyroid lymphomas", "correct": false}], "correct_answer": "C. Papillary carcinoma of thyroid", "question_images": [], "explanation_images": [], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference:</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Sudden rapid enlargement of a pre- existent thyroid swelling was noticed in a 75 year old woman. She now has difficulty swallowing and talking . What is the probable diagnosis?", "options": [{"label": "A", "text": "Local invasion of surrounding structures", "correct": false}, {"label": "B", "text": "Cervical Lymph node enlargement", "correct": false}, {"label": "C", "text": "Anaplastic thyroid cancer", "correct": true}, {"label": "D", "text": "Hurthle Cell follicular carcinoma", "correct": false}], "correct_answer": "C. Anaplastic thyroid cancer", "question_images": [], "explanation_images": [], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference:</li><li>↳ Schwartz’s principles of surgery 10 th edition page 1550</li><li>↳ Sabiston textbook of surgery 20 th edition pg 910</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following swellings do not move with deglutition?", "options": [{"label": "A", "text": "Thyroglossal cyst", "correct": false}, {"label": "B", "text": "Sub hyoid bursitis", "correct": false}, {"label": "C", "text": "Cystic hygroma", "correct": true}, {"label": "D", "text": "Dermoid cysts attached to hyoid bone", "correct": false}], "correct_answer": "C. Cystic hygroma", "question_images": [], "explanation_images": [], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference: Schwartz’s principles of surgery 10 th edition page no. 1522</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient with 3x2 cm nodular thyroid swelling underwent a thyroid profile. Normal T4 and TSH levels were seen. What is the next best step in management?", "options": [{"label": "A", "text": "Thyroid antibodies", "correct": false}, {"label": "B", "text": "USG neck", "correct": true}, {"label": "C", "text": "Fine needle aspiration cytology", "correct": false}, {"label": "D", "text": "Radioactive iodine uptake", "correct": false}], "correct_answer": "B. USG neck", "question_images": [], "explanation_images": [], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference: Bailey and Love:</li><li>↳ Sabiston textbook of surgery 20 th edition, page 890</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A radionuclide scan done in a patient with a thyroid nodular swelling, shows the following image. How much is the risk of this pathology being benign?", "options": [{"label": "A", "text": "80%", "correct": true}, {"label": "B", "text": "20%", "correct": false}, {"label": "C", "text": "90%", "correct": false}, {"label": "D", "text": "10%", "correct": false}], "correct_answer": "A. 80%", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/26/screenshot-2023-04-26-123631_zipAvOB.jpg"], "explanation_images": [], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference:</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Most usual cause of thyroid storm in thyroidectomy is?", "options": [{"label": "A", "text": "Due to parathyroid gland", "correct": false}, {"label": "B", "text": "Rough handling of thyroid during surgery", "correct": false}, {"label": "C", "text": "Infections", "correct": false}, {"label": "D", "text": "Inadequate patient preparation", "correct": true}], "correct_answer": "D. Inadequate patient preparation", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/26/screenshot-2023-04-26-123631_JJR1jOY.jpg"], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference:</li><li>↳ Schwartz’s principles of surgery 10 th edition, page 1534</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "The following statement best describes Hartley-Dunhill procedure:", "options": [{"label": "A", "text": "Partial resection of each lobe removing the bulk of the gland", "correct": false}, {"label": "B", "text": "Total resection of lobes on one side, with partial resection of the other side", "correct": true}, {"label": "C", "text": "Total resection of one lobe with partial resection of three lobes", "correct": false}, {"label": "D", "text": "Resection of two lobe with the removal of isthmus", "correct": false}], "correct_answer": "B. Total resection of lobes on one side, with partial resection of the other side", "question_images": [], "explanation_images": [], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference:</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A histopathology section of thyroid gland is shown here. The arrow marks certain cells of the thyroid gland. Which carcinoma will arise from the following cells? Papillary Follicular Hurthle cell Anaplastic Medullary", "options": [{"label": "A", "text": "1,4,5", "correct": false}, {"label": "B", "text": "2,3", "correct": false}, {"label": "C", "text": "2,3,4", "correct": false}, {"label": "D", "text": "1,2,3,4", "correct": true}], "correct_answer": "D. 1,2,3,4", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/26/picture1_JlmzGEb.png"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/26/screenshot-2023-04-26-123631_lbhW22D.jpg"], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference :</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 20 year old female presented with a painless enlargement in the midline of her neck. The histology of the tissue is as follows. How will you diagnose this case?", "options": [{"label": "A", "text": "Grave’s disease", "correct": false}, {"label": "B", "text": "Non hodgkin's lymphoma", "correct": false}, {"label": "C", "text": "Medullary carcinoma", "correct": false}, {"label": "D", "text": "Hashimoto’s thyroiditis", "correct": true}], "correct_answer": "D. Hashimoto’s thyroiditis", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/26/picture1_N2t4oyv.png"], "explanation_images": [], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference:</li><li>↳ Schwartz’s Principles of Surgery- 1oth edition page no 1535</li><li>↳ Sabiston Textbook of surgery 20 th edition- page 891</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 40-year-old lady with painless neck swelling presented with palpitations and weight loss. Her thyroid function tests were done which revealed elevated T3, T4, low TSH and negative TSH-RAb. Iodine scan showed multiple thyroid nodules with increased iodine uptake. She was started on initial anti-thyroid treatment. What will be your next step in management?", "options": [{"label": "A", "text": "Total/Near total thyroidectomy", "correct": true}, {"label": "B", "text": "Long term antithyroid medication", "correct": false}, {"label": "C", "text": "Subtotal thyroidectomy", "correct": false}, {"label": "D", "text": "Radioactive iodine", "correct": false}], "correct_answer": "A. Total/Near total thyroidectomy", "question_images": [], "explanation_images": [], "explanation": "<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 40 year old female presented with malaise, fever, painful neck swelling. She had recently recovered from an episode of URTI. Lab reports show elevated ESR, and elevated T4 levels. How will you manage this patient?", "options": [{"label": "A", "text": "Antivirals", "correct": false}, {"label": "B", "text": "Antibiotics", "correct": false}, {"label": "C", "text": "NSAIDs", "correct": true}, {"label": "D", "text": "Antithyroid drugs", "correct": false}], "correct_answer": "C. NSAIDs", "question_images": [], "explanation_images": [], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference:</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the incorrect option with respect to follicular carcinoma:", "options": [{"label": "A", "text": "Thyroglobulin levels can be used to monitor patients for recurrence.", "correct": false}, {"label": "B", "text": "Hematogenous spread is more common than lymphatic", "correct": false}, {"label": "C", "text": "Mortality rate is twice that of papillary", "correct": false}, {"label": "D", "text": "Osteoblastic bone metastasis is seen", "correct": true}], "correct_answer": "D. Osteoblastic bone metastasis is seen", "question_images": [], "explanation_images": [], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference:</li><li>↳ Schwartz’s principles of surgery 10 th edition page 1544</li><li>↳ Sabiston textbook of surgery 20 th edition pg 904</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 35 year old patient came to the surgeon with a thyroid swelling for 1 year. O/E the patient appeared euthyroid. Lymphadenopathy was a significant finding. The swelling was 3.5cm in size and was firm and immobile. A biopsy of the swelling showed the following histopathological picture. Choose the incorrect statement regarding management and post-op care.", "options": [{"label": "A", "text": "Prophylactic neck dissection is done.", "correct": false}, {"label": "B", "text": "Calcium supplementation is given post op", "correct": false}, {"label": "C", "text": "Hemithyroidectomy is done", "correct": true}, {"label": "D", "text": "Thyroxine is withheld after surgery", "correct": false}], "correct_answer": "C. Hemithyroidectomy is done", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/26/screenshot-2023-04-26-123631_tjA8Umq.jpg"], "explanation_images": [], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference:</li><li>↳ Sabiston textbook of surgery 20 th edition pg 907</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "HPE was done on a 50 year old patient with a history of a diffuse enlargement of thyroid gland. Lab studies revealed low T3, T4, high TSH and the presence of anti TPO antibodies. The HPE showed enlarged cells with abundant eosinophilic cytoplasm. Which of the following malignancies is commonly associated with this condition?", "options": [{"label": "A", "text": "Medullary carcinoma", "correct": false}, {"label": "B", "text": "Anaplastic carcinoma", "correct": false}, {"label": "C", "text": "Hurthle cell carcinoma", "correct": false}, {"label": "D", "text": "Thyroid lymphoma", "correct": true}], "correct_answer": "D. Thyroid lymphoma", "question_images": [], "explanation_images": [], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference:</li><li>↳ Bailey and Love 27 th edition page 821</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old male presented with rapidly growing neck mass. On examination, the mass was hard and bilateral neck nodes were palpable. He also gives history of recent unexplained diarrhea. Which of the following thyroid malignancies will present with the following findings on histopathological examination?", "options": [{"label": "A", "text": "Papillary carcinoma", "correct": false}, {"label": "B", "text": "Medullary carcinoma", "correct": true}, {"label": "C", "text": "Anaplastic carcinoma", "correct": false}, {"label": "D", "text": "Follicular carcinoma", "correct": false}], "correct_answer": "B. Medullary carcinoma", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/26/screenshot-2023-04-26-123631_a76Ac3u.jpg"], "explanation_images": [], "explanation": "<p><strong>References:</strong></p><ul><li>↳ Reference:</li><li>↳ Robbins basic pathology 1oth edition, page 768</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following statements is false with respect to the cancer shown in the below histopathological slide?", "options": [{"label": "A", "text": "It has a much poorer prognosis compared to follicular thyroid cancer", "correct": false}, {"label": "B", "text": "The investigation of choice for its diagnosis is FNAC", "correct": true}, {"label": "C", "text": "They are often bilateral and multifocal", "correct": false}, {"label": "D", "text": "Total thyroidectomy is the surgery of choice", "correct": false}], "correct_answer": "B. The investigation of choice for its diagnosis is FNAC", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/26/screenshot-2023-04-26-123631_fhf1TGA.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/26/screenshot-2023-04-26-123631_2Xcqwsm.jpg"], "explanation": "<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Given below is a picture of the pharyngeal pouches and arches. Which of the following structures are arises from the 3rd pharyngeal pouch?", "options": [{"label": "A", "text": "Thymus and inferior parathyroid gland", "correct": true}, {"label": "B", "text": "Thymus and superior parathyroid gland", "correct": false}, {"label": "C", "text": "Only superior parathyroid glands", "correct": false}, {"label": "D", "text": "Only inferior parathyroid glands", "correct": false}], "correct_answer": "A. Thymus and inferior parathyroid gland", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/12/picture1_19yEKTy.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. A) Thymus and inferior parathyroid gland</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B : Thymus and superior parathyroid gland . Incorrect . The superior parathyroid gland arises from the 4th pharyngeal pouch , not the 3rd.</li><li>• Option B</li><li>• Thymus and superior parathyroid gland</li><li>• Incorrect</li><li>• superior parathyroid gland</li><li>• 4th pharyngeal pouch</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The parathyroid glands develop from the third and fourth pharyngeal pouches . The thymus also develops from the third pouch . As it descends, the thymus takes the associated parathyroid gland with it , which explains why the inferior parathyroid , which arises from the third pharyngeal pouch , normally lies inferior to the superior gland .</li><li>➤ The parathyroid glands develop from the third and fourth pharyngeal pouches</li><li>➤ thymus also develops from the third pouch</li><li>➤ descends,</li><li>➤ thymus</li><li>➤ parathyroid gland with it</li><li>➤ inferior parathyroid</li><li>➤ arises from the third pharyngeal pouch</li><li>➤ inferior to the superior gland</li><li>➤ The developing thyroid lobes amalgamate with the structures that arise in the fourth pharyngeal pouch, i.e., the superior parathyroid gland and the ultimobranchial body.</li><li>➤ The developing thyroid lobes amalgamate with the structures that arise in the fourth pharyngeal pouch, i.e., the superior parathyroid gland and the ultimobranchial body.</li><li>➤ Ref : Bailey and Love, 28th Ed. Pg 850</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28th Ed. Pg 850</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "What is the most common site for ectopic inferior parathyroid gland?", "options": [{"label": "A", "text": "Thyro-thymic tract", "correct": true}, {"label": "B", "text": "Intra-thyroidal", "correct": false}, {"label": "C", "text": "Near upper pole", "correct": false}, {"label": "D", "text": "Mediastinal", "correct": false}], "correct_answer": "A. Thyro-thymic tract", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/12/picture2.jpg"], "explanation": "<p><strong>Ans. A) Thyro-thymic tract</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Intra-thyroidal - While parathyroid glands can be found within the thyroid gland itself , this is less common than in the thyro-thymic tract.</li><li>• Option B:</li><li>• Intra-thyroidal</li><li>• parathyroid glands</li><li>• found within the thyroid gland itself</li><li>• Option C: Near upper pole - Parathyroid glands are generally located near the poles of the thyroid gland . However, the 'near upper pole' is not the most common site for ectopic parathyroid glands . Typically, the superior parathyroids are located near the upper pole of the thyroid, while the inferior parathyroids are located near the lower pole.</li><li>• Option C:</li><li>• Near upper pole</li><li>• Parathyroid glands</li><li>• located near the poles of the thyroid gland</li><li>• 'near upper pole' is not the most common site for ectopic parathyroid glands</li><li>• Option D: Mediastinal - Mediastinal ectopic parathyroid glands are those that have descended past the normal location into the chest cavity . This is a less common site for ectopic glands compared to the thyro-thymic tract but is still a possible location for ectopic inferior parathyroid glands.</li><li>• Option D:</li><li>• Mediastinal</li><li>• Mediastinal ectopic parathyroid glands</li><li>• descended past the normal location into the chest cavity</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most common site for ectopic inferior parathyroid glands is the thyro-thymic tract , reflecting the embryological descent of these glands from the third pharyngeal pouch .</li><li>➤ most common site for ectopic inferior parathyroid glands</li><li>➤ thyro-thymic tract</li><li>➤ reflecting the embryological descent of these glands</li><li>➤ third pharyngeal pouch</li><li>➤ Ref: Bailey 28 th Ed. Fig 56.1</li><li>➤ Ref: Bailey 28 th Ed. Fig 56.1</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45 years old postmenopausal woman, presented to the OPD with back pains. Initial screening shows serum calcium levels of 11.7mg%, Vit. D is 55 ng/ml and elevated PTH. What might be the most common cause of such clinical manifestations?", "options": [{"label": "A", "text": "Tumour lysis syndrome", "correct": false}, {"label": "B", "text": "Parathyroid Adenoma", "correct": true}, {"label": "C", "text": "Secondary hyperparathyroidism", "correct": false}, {"label": "D", "text": "Multiglandular Parathyroid hyperplasia", "correct": false}], "correct_answer": "B. Parathyroid Adenoma", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/12/picture3.jpg"], "explanation": "<p><strong>Ans. B) Parathyroid Adenoma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Tumour Lysis Syndrome - This condition occurs when a large number of tumor cells are lysed rapidly , releasing their contents into the bloodstream. This can lead to hypercalcemia due to the high influx of intracellular calcium into the bloodstream. This is seen in setting of chemotherapy for leukemias, which does not match the clinical scenario. In this case, PTH levels would not be elevated.</li><li>• Option A:</li><li>• Tumour Lysis Syndrome</li><li>• large number of tumor cells are lysed rapidly</li><li>• contents into the bloodstream.</li><li>• hypercalcemia</li><li>• high influx of intracellular calcium into the bloodstream.</li><li>• Option C: Secondary Hyperparathyroidism - This condition arises due to another disease that causes low calcium levels , prompting the parathyroid glands to overproduce PTH to compensate . Common causes include chronic kidney disease and vitamin D deficiency, which are not indicated in this patient due to her normal vitamin D levels.</li><li>• Option C:</li><li>• Secondary Hyperparathyroidism</li><li>• another disease that causes low calcium levels</li><li>• parathyroid glands to overproduce PTH to compensate</li><li>• Option D: Multiglandular Parathyroid Hyperplasia - This refers to the enlargement and increased activity of more than one parathyroid gland . It's often seen in genetic conditions such as Multiple Endocrine Neoplasia (MEN) syndromes. While this could cause elevated PTH levels, it is less common than a single adenoma.</li><li>• Option D:</li><li>• Multiglandular Parathyroid Hyperplasia</li><li>• enlargement and increased activity of more than one parathyroid gland</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ A parathyroid adenoma is the most common cause of primary hyperparathyroidism, which is characterized by elevated PTH and calcium levels , with normal vitamin D levels , especially in the context of a postmenopausal woman with back pains .</li><li>➤ parathyroid adenoma</li><li>➤ most common cause of primary hyperparathyroidism,</li><li>➤ elevated PTH and calcium levels</li><li>➤ normal vitamin D levels</li><li>➤ postmenopausal woman with back pains</li><li>➤ Causes of hypercalcemia:</li><li>➤ Causes of hypercalcemia:</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 875</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 875</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of the following are seen in symptomatic primary hyperparathyroidism except?", "options": [{"label": "A", "text": "Renal calculi", "correct": false}, {"label": "B", "text": "Painful bones", "correct": false}, {"label": "C", "text": "Mental confusion", "correct": false}, {"label": "D", "text": "Skin rash", "correct": true}], "correct_answer": "D. Skin rash", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Skin rash</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Renal calculi - Renal calculi are a common manifestation of primary hyperparathyroidism (PHPT). The condition can lead to hypercalcemia, which in turn can cause calcium to precipitate in kidneys leading to calcium oxalate stones.</li><li>• Option A:</li><li>• Renal calculi</li><li>• common manifestation of primary hyperparathyroidism</li><li>• Option B: Painful bones - Patients with PHPT can experience bone pain and skeletal fragility . This is due to excess PTH stimulating bone resorption, which can lead to osteitis fibrosa cystica, a condition where bones become weak and deformed.</li><li>• Option B:</li><li>• Painful bones</li><li>• PHPT can experience bone pain</li><li>• skeletal fragility</li><li>• Option C: Mental confusion - Elevated calcium levels associated with PHPT can result in neuropsychiatric manifestations , including mental confusion, fatigue, depression, and memory impairment , often referred to as \"psychiatric moans\"</li><li>• Option C:</li><li>• Mental confusion</li><li>• Elevated calcium levels</li><li>• PHPT</li><li>• neuropsychiatric manifestations</li><li>• mental confusion, fatigue, depression, and memory impairment</li><li>• \"psychiatric moans\"</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Skin rash is not a typical manifestation of symptomatic primary hyperparathyroidism, which is classically characterized by symptoms involving the bones, kidneys, gastrointestinal tract, and central nervous system , summarized by the phrase ‘painful bones, renal stones, abdominal groans, fatigue overtones and psychiatric moans’ .</li><li>➤ Skin rash</li><li>➤ not a typical manifestation of symptomatic primary hyperparathyroidism,</li><li>➤ symptoms involving the bones, kidneys, gastrointestinal tract,</li><li>➤ central nervous system</li><li>➤ phrase ‘painful bones, renal stones, abdominal groans, fatigue overtones and psychiatric moans’</li><li>➤ Patients are typically identified incidentally with elevated total calcium or following routine assessment of bone densitometry (DEXA scan) . Most patients will, however, have some vague constitutional symptoms, such as fatigue, muscle weakness, depression or some mild memory impairment on questioning. The presence of kidney stones remains the most common clinical manifestation of symptomatic PHPT.</li><li>➤ Patients are typically identified incidentally with elevated total calcium or following routine assessment of bone densitometry (DEXA scan) .</li><li>➤ incidentally</li><li>➤ bone densitometry (DEXA scan)</li><li>➤ Most patients will, however, have some vague constitutional symptoms, such as fatigue, muscle weakness, depression or some mild memory impairment on questioning.</li><li>➤ The presence of kidney stones remains the most common clinical manifestation of symptomatic PHPT.</li><li>➤ most common clinical manifestation</li><li>➤ Ref : Bailey and Love, 28 th Ed. PG 875</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. PG 875</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of the following will be seen in the biochemical panel of a patient with primary Hyperparathyroidism except?", "options": [{"label": "A", "text": "Hypercalcemia", "correct": false}, {"label": "B", "text": "Normal serum creatinine", "correct": false}, {"label": "C", "text": "Decreased urinary excretion of phosphate", "correct": true}, {"label": "D", "text": "Increased serum ALP", "correct": false}], "correct_answer": "C. Decreased urinary excretion of phosphate", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Decreased urinary excretion of phosphate</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Hypercalcemia - This is a hallmark feature of PHPT due to the overproduction of parathyroid hormone (PTH), leading to increased calcium reabsorption in the kidneys , increased calcium release from bones , and increased calcium absorption from the intestine .</li><li>• Option A:</li><li>• Hypercalcemia</li><li>• hallmark feature of PHPT</li><li>• overproduction of parathyroid hormone</li><li>• increased calcium reabsorption in the kidneys</li><li>• increased calcium release from bones</li><li>• increased calcium absorption from the intestine</li><li>• Option B: Normal serum creatinine - PHPT does not necessarily affect renal function ; therefore, serum creatinine levels may remain within normal ranges unless there is concomitant kidney disease .</li><li>• Option B:</li><li>• Normal serum creatinine</li><li>• does not necessarily affect renal function</li><li>• serum creatinine levels may remain within normal ranges</li><li>• concomitant kidney disease</li><li>• Option D: Increased serum ALP (Alkaline Phosphatase) - Serum ALP may be elevated in PHPT if there is bone involvement . PTH stimulates bone turnover, which can raise ALP levels as it is an enzyme associated with bone formation.</li><li>• Option D:</li><li>• Increased serum ALP (Alkaline Phosphatase)</li><li>• Serum ALP</li><li>• elevated in PHPT if there is bone involvement</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In primary hyperparathyroidism , the biochemical profile usually includes hypercalcemia, normal serum creatinine , increased urinary excretion of phosphate , and possibly increased serum alkaline phosphatase if bone disease is present . Decreased urinary excretion of phosphate is not a feature of PHPT.</li><li>➤ primary hyperparathyroidism</li><li>➤ biochemical profile usually includes hypercalcemia, normal serum creatinine</li><li>➤ increased urinary excretion of phosphate</li><li>➤ increased serum alkaline phosphatase</li><li>➤ bone disease is present</li><li>➤ PHPT is a biochemical diagnosis . Only when the disease has been confirmed biochemically should localization studies be undertaken. PHPT is defined as an elevated total , or more specifically ionized, calcium in the presence of an inappropriately elevated or unsuppressed PTH. It is associated with a low serum phosphate in the setting of normal creatinine and vitamin D levels; 24-hour urinary excretion of calcium may be normal or elevated . It is important to perform a 24-hour urinary collection to rule out the presence of the rare familial hypocalciuric hypercalcemia (FHH). Alkaline phosphatase may be elevated in patients in whom there is concomitant bone disease.</li><li>➤ PHPT is a biochemical diagnosis . Only when the disease has been confirmed biochemically should localization studies be undertaken.</li><li>➤ PHPT is a biochemical diagnosis</li><li>➤ PHPT is defined as an elevated total , or more specifically ionized, calcium in the presence of an inappropriately elevated or unsuppressed PTH.</li><li>➤ PHPT is defined as an elevated total</li><li>➤ It is associated with a low serum phosphate in the setting of normal creatinine and vitamin D levels; 24-hour urinary excretion of calcium may be normal or elevated .</li><li>➤ 24-hour urinary excretion of calcium may be normal or elevated</li><li>➤ It is important to perform a 24-hour urinary collection to rule out the presence of the rare familial hypocalciuric hypercalcemia (FHH).</li><li>➤ Alkaline phosphatase may be elevated in patients in whom there is concomitant bone disease.</li><li>➤ Alkaline phosphatase may be elevated in patients</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 876</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 876</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50 years old female was diagnosed with primary hyperparathyroidism. USG neck revealed a single adenoma of the left parathyroid gland. What’s the most preferred technique to determine its localization?", "options": [{"label": "A", "text": "Cervical exploration", "correct": false}, {"label": "B", "text": "Parathyroid venous sampling", "correct": false}, {"label": "C", "text": "4D CT scan neck", "correct": false}, {"label": "D", "text": "Sestamibi scan", "correct": true}], "correct_answer": "D. Sestamibi scan", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Sestamibi scan</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A: Preoperative localisation studies for PHPT were considered less important than identifying an experienced surgeon. However, with a shift away from the traditional four gland (cervical neck) exploration to more minimally invasive procedures, accurate preoperative identification is critically important to guide surgical strategy</li><li>• Option A:</li><li>• accurate preoperative identification is critically important to guide surgical strategy</li><li>• Option B: Selective venous sampling for PTH can allow accurate localisation of adenomas but an experienced interventional radiologist is vital for success .</li><li>• Option B:</li><li>• experienced interventional radiologist is vital for success</li><li>• Option C: Multiphase CT imaging (4D-CT) has become widely utilized to localise disease. It gives both anatomical and functional information about the parathyroid gland. The potential disadvantage of 4D-CT scanning is the higher radiation dose when compared with traditional imaging modalities.</li><li>• Option C:</li><li>• It gives both anatomical and functional information</li><li>• potential disadvantage of 4D-CT scanning is the higher radiation dose</li><li>• Ref : Bailey and Love, 28 th Ed., Pg. 875, 876</li><li>• Ref</li><li>• : Bailey and Love, 28 th Ed., Pg. 875, 876</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In total parathyroidectomy for multi-glandular disease, all 4 parathyroid glands are removed and bits are re-implanted in which part of the body?", "options": [{"label": "A", "text": "Sternocleidomastoid muscle", "correct": false}, {"label": "B", "text": "Behind thyroid gland", "correct": false}, {"label": "C", "text": "Forearm", "correct": true}, {"label": "D", "text": "Abdomen", "correct": false}], "correct_answer": "C. Forearm", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Forearm</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Sternocleidomastoid muscle - This is not a common site for auto-transplantation of parathyroid tissue . While it is easily accessible during neck surgery, it is less preferred due to the potential for difficulty in monitoring and resecting the tissue if necessary.</li><li>• Option A:</li><li>• Sternocleidomastoid muscle</li><li>• not a common site for auto-transplantation of parathyroid tissue</li><li>• Option B: Behind the thyroid gland - Re-implantation behind the thyroid gland is not a standard practice because it can make it challenging to distinguish between recurrent disease in the neck and the transplanted tissue.</li><li>• Option B:</li><li>• Behind the thyroid gland</li><li>• Re-implantation</li><li>• thyroid gland is not a standard practice</li><li>• Option D: Abdomen - Although the abdomen is a site that could technically be used for transplantation , it is not preferred due to the complexity of re-operation in this area and the inability to easily monitor the graft.</li><li>• Option D:</li><li>• Abdomen</li><li>• abdomen is a site that could technically be used for transplantation</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In total parathyroidectomy for multi-glandular parathyroid disease , the standard practice is to re-implant small pieces of parathyroid tissue into the brachioradialis muscle of the non-dominant forearm to facilitate monitoring and potential future re-operation.</li><li>➤ total parathyroidectomy for multi-glandular parathyroid disease</li><li>➤ standard practice is to re-implant small pieces of parathyroid tissue</li><li>➤ brachioradialis muscle</li><li>➤ non-dominant forearm</li><li>➤ “All four glands can be resected and a forearm auto-transplant created. Small pieces of parathyroid are sutured into pockets created in the brachioradialis muscle of the non-dominant forearm.”</li><li>➤ “All four glands can be resected and a forearm auto-transplant created. Small pieces of parathyroid are sutured into pockets created in the brachioradialis muscle of the non-dominant forearm.”</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 880</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 880</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 67 years old male underwent a total thyroidectomy for papillary carcinoma of the thyroid gland. The parathyroid glands were accidentally removed. Where can the surgeon re implant these glands?", "options": [{"label": "A", "text": "Brachioradialis muscle of non-dominant forearm", "correct": false}, {"label": "B", "text": "Brachioradialis muscle of dominant forearm", "correct": false}, {"label": "C", "text": "Sternocleidomastoid", "correct": true}, {"label": "D", "text": "All 4 glands are reimplanted in normal anatomical locations", "correct": false}], "correct_answer": "C. Sternocleidomastoid", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Sternocleidomastoid</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ If the parathyroid glands are inadvertently removed during thyroidectomy , they may be re-implanted into the sternocleidomastoid muscle to maintain more physiological parathyroid function and allow for surgical accessibility if needed in the future.</li><li>➤ parathyroid glands</li><li>➤ inadvertently removed during thyroidectomy</li><li>➤ re-implanted into the sternocleidomastoid muscle to maintain more physiological parathyroid function</li><li>➤ surgical accessibility</li><li>➤ In total parathyroidectomy for “multiglandular hyperplasia”, all four glands can be resected and a forearm auto-transplant created . Small pieces of parathyroid are sutured into pockets created in the brachioradialis muscle of the non-dominant forearm . This will allow easier diagnosis of recurrence of hyperparathyroidism</li><li>➤ In total parathyroidectomy for “multiglandular hyperplasia”, all four glands can be resected and a forearm auto-transplant created . Small pieces of parathyroid are sutured into pockets created in the brachioradialis muscle of the non-dominant forearm . This will allow easier diagnosis of recurrence of hyperparathyroidism</li><li>➤ total parathyroidectomy</li><li>➤ “multiglandular hyperplasia”,</li><li>➤ four glands</li><li>➤ resected and a forearm auto-transplant created</li><li>➤ in the brachioradialis muscle of the non-dominant forearm</li><li>➤ Ref : Bailey and Love, 28 th Pg 880</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Pg 880</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 37-year-old female patient is undergoing a focused parathyroidectomy for parathyroid adenoma. According to the Miami criteria, for the resection to be considered appropriate, the intra operative drop in parathyroid hormone level should be around?", "options": [{"label": "A", "text": "More than half the maximum pre-operative value in 30 mins", "correct": false}, {"label": "B", "text": "More than half the maximum preoperative value in 10 mins", "correct": true}, {"label": "C", "text": "More than one third the maximum preoperative value in 30 mins", "correct": false}, {"label": "D", "text": "More than one third the maximum pre-operative value in 10 mins", "correct": false}], "correct_answer": "B. More than half the maximum preoperative value in 10 mins", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/12/picture4.jpg"], "explanation": "<p><strong>Ans. B) More than half the maximum pre-operative value in 10 mins</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Miami criteria were developed to determine the extent of resection . A drop in the PTH into the normal range and to less than half the maximum preoperative PTH at 10 minutes appears to accurately predict single-gland disease .</li><li>➤ Miami criteria</li><li>➤ determine the extent of resection</li><li>➤ drop in the PTH</li><li>➤ normal range and to less than half the maximum preoperative PTH at 10 minutes</li><li>➤ accurately predict single-gland disease</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 880</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 880</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old male was undergoing routine scanning when he was diagnosed with asymptomatic primary hyperparathyroidism. All of the following are criteria for surgical intervention in a case of primary HPTH except?", "options": [{"label": "A", "text": "Age &lt; 50years", "correct": false}, {"label": "B", "text": "Serum calcium 0.5 mg% above upper limit /dL", "correct": true}, {"label": "C", "text": "DEXA Scan T score -2.5 at lumbar spine", "correct": false}, {"label": "D", "text": "24-hour urinary calcium &gt;10 mmol", "correct": false}], "correct_answer": "B. Serum calcium 0.5 mg% above upper limit /dL", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/12/picture5.jpg"], "explanation": "<p><strong>Ans. B) Serum calcium 0.5 mg% above upper limit</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Age &lt; 50 years - This is one of the indications for surgery. Younger patients are more likely to benefit from surgical intervention due to the potential for longer-term complications of the disease if left untreated.</li><li>• Option A:</li><li>• Age &lt; 50 years</li><li>• Younger patients are more likely to benefit from surgical intervention</li><li>• Option C: DEXA Scan T score -2.5 at lumbar spine - A T-score of -2.5 or lower at any major site (lumbar spine, hip, or forearm) is an indication for surgery because it reflects significant bone loss, which could be attributable to HPTH.</li><li>• Option C:</li><li>• DEXA Scan T score -2.5 at lumbar spine</li><li>• T-score of -2.5 or lower at any major site</li><li>• indication for surgery</li><li>• Option D: 24-hour urinary calcium &gt;10 mmol/dL - This indicates increased calcium excretion , which increases the risk for kidney stones , and is a criterion for considering surgery in the management of HPTH.</li><li>• Option D:</li><li>• 24-hour urinary calcium &gt;10 mmol/dL</li><li>• indicates increased calcium excretion</li><li>• increases the risk for kidney stones</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In asymptomatic primary hyperparathyroidism , surgical intervention is indicated for patients younger than 50 years , those with a serum calcium more than 1 mg% above the upper limit of normal , a DEXA scan T-score of -2.5 or less at any major site , or a 24-hour urinary calcium excretion greater than 10 mmol/dL .</li><li>➤ asymptomatic primary hyperparathyroidism</li><li>➤ surgical intervention</li><li>➤ patients younger than 50 years</li><li>➤ serum calcium more than 1 mg%</li><li>➤ upper limit of normal</li><li>➤ DEXA scan T-score of -2.5 or less at any major site</li><li>➤ 24-hour urinary calcium excretion greater than 10 mmol/dL</li><li>➤ Serum calcium should be more than 1 mg% above upper limit of normal. In patients not fulfilling below criteria, medical management can be tried for asymptomatic primary hyperparathyroidism.</li><li>➤ Serum calcium should be more than 1 mg% above upper limit of normal.</li><li>➤ Serum calcium should be more than 1 mg% above upper limit of normal.</li><li>➤ In patients not fulfilling below criteria, medical management can be tried for asymptomatic primary hyperparathyroidism.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 879</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 879</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of the following are components of MEN 1 syndrome except?", "options": [{"label": "A", "text": "Medullary thyroid carcinoma", "correct": true}, {"label": "B", "text": "Multi-glandular parathyroid gland hyperplasia", "correct": false}, {"label": "C", "text": "Insulinoma", "correct": false}, {"label": "D", "text": "Prolactinoma", "correct": false}], "correct_answer": "A. Medullary thyroid carcinoma", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Medullary thyroid carcinoma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Multi-glandular parathyroid gland hyperplasia - This is a classic feature of MEN 1 . Almost all patients with MEN 1 develop parathyroid hyperplasia, leading to primary hyperparathyro</li><li>• Option B:</li><li>• Multi-glandular parathyroid gland hyperplasia</li><li>• classic feature of MEN 1</li><li>• Option C: Insulinoma - Insulinomas are pancreatic endocrine tumors that can occur as a part of MEN 1 . Although less common than gastrinoma , they are one of the characteristic features of this syndrome.</li><li>• Option C:</li><li>• Insulinoma</li><li>• pancreatic endocrine tumors</li><li>• occur</li><li>• part of MEN 1</li><li>• gastrinoma</li><li>• Option D: Prolactinoma - Prolactinomas are pituitary tumors that often occur in MEN 1 . They are the most common type of pituitary adenomas found in this syndrome .</li><li>• Option D:</li><li>• Prolactinoma</li><li>• pituitary tumors that often occur in MEN 1</li><li>• most common type of pituitary adenomas found in this syndrome</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Medullary thyroid carcinoma is not a component of MEN 1 syndrome , which is characterized by the triad of parathyroid hyperplasia , pancreatic endocrine tumors (like gastrinomas&gt;insulinomas), and pituitary tumors (commonly prolactinomas).</li><li>➤ Medullary thyroid carcinoma</li><li>➤ not a component of MEN 1 syndrome</li><li>➤ triad of parathyroid hyperplasia</li><li>➤ pancreatic endocrine tumors</li><li>➤ pituitary tumors</li><li>➤ MEN type 1 is a rare autosomal dominant syndrome consisting of tumors of the parathyroids, endocrine pancreas and the pituitary (the three Ps) . It can also be associated with adrenal adenomas or carcinoma, foregut carcinoids and lipomas. Men 1 is a tumour suppressor gene . Mutations of MEN 1 gene coding for MENIN protein are responsible for MEN 1. Patients typically present with young onset (20–30 years of age) of symptomatic hyperparathyroidism and over 95% of patients will have PHPT before the age of 40 years.</li><li>➤ MEN type 1 is a rare autosomal dominant syndrome consisting of tumors of the parathyroids, endocrine pancreas and the pituitary (the three Ps) .</li><li>➤ (the three Ps)</li><li>➤ It can also be associated with adrenal adenomas or carcinoma, foregut carcinoids and lipomas.</li><li>➤ Men 1 is a tumour suppressor gene . Mutations of MEN 1 gene coding for MENIN protein are responsible for MEN 1.</li><li>➤ Men 1 is a tumour suppressor gene</li><li>➤ MENIN protein</li><li>➤ Patients typically present with young onset (20–30 years of age) of symptomatic hyperparathyroidism and over 95% of patients will have PHPT before the age of 40 years.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 882</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 882</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which is the most common feature of MEN 2A syndrome?", "options": [{"label": "A", "text": "Unilateral pheochromocytoma", "correct": false}, {"label": "B", "text": "Bilateral pheochromocytoma", "correct": false}, {"label": "C", "text": "Pancreatic cancer", "correct": false}, {"label": "D", "text": "Medullary thyroid cancer", "correct": true}], "correct_answer": "D. Medullary thyroid cancer", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Medullary thyroid cancer</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• MEN type 2A consists of medullary thyroid carcinoma (MTC), unilateral or bilateral pheochromocytomas and PHPT due to multiglandular disease . PHPT occurs in approximately 20% of patients and is associated with mutations in codon 634 in the RET proto-oncogene .</li><li>• MEN type 2A consists of medullary thyroid carcinoma (MTC), unilateral or bilateral pheochromocytomas and PHPT due to multiglandular disease .</li><li>• MEN type 2A</li><li>• medullary thyroid carcinoma</li><li>• unilateral or bilateral pheochromocytomas</li><li>• PHPT due to multiglandular disease</li><li>• PHPT occurs in approximately 20% of patients and is associated with mutations in codon 634 in the RET proto-oncogene .</li><li>• PHPT</li><li>• approximately 20% of patients</li><li>• associated with mutations in codon 634</li><li>• RET proto-oncogene</li><li>• MEN 2 syndrome:</li><li>• MEN 2 syndrome:</li><li>• Medullary Thyroid carcinoma (90-100%) Pheochromocytoma (10-60%)</li><li>• Medullary Thyroid carcinoma (90-100%)</li><li>• Pheochromocytoma (10-60%)</li><li>• Ref : Bailey and Love, 28 th Ed. Pg 882</li><li>• Ref</li><li>• : Bailey and Love, 28 th Ed. Pg 882</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the incorrect statement with respect to MEN syndrome?", "options": [{"label": "A", "text": "Mucosal neuromas belong to MEN 3 syndrome", "correct": false}, {"label": "B", "text": "MEN syndrome is more common at an older age", "correct": true}, {"label": "C", "text": "MEN 4 syndrome is associated with a cyclin dependent kinase inhibitor CDKI mutation", "correct": false}, {"label": "D", "text": "Tumors are aggressive and bilateral in nature", "correct": false}], "correct_answer": "B. MEN syndrome is more common at an older age", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) MEN syndrome is more common at an older age</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A: Mucosal neuromas belong to MEN 3 syndrome - Mucosal neuromas are a feature of MEN 2B , which is also referred to as MEN 3 by some classifications . MEN 2B includes medullary thyroid carcinoma, pheochromocytoma, mucosal neuromas, and a marfanoid habitus.</li><li>• Option A:</li><li>• Mucosal neuromas belong to MEN 3 syndrome</li><li>• MEN 2B</li><li>• MEN 3 by some classifications</li><li>• Option C: MEN 4 syndrome is associated with a cyclin dependent kinase inhibitor (CDKI) mutation - This is correct . MEN 4 is associated with mutations in the CDK inhibitor genes, which can lead to a phenotype similar to MEN 1, with tumors in multiple glands.</li><li>• Option C:</li><li>• MEN 4 syndrome is associated with a cyclin dependent kinase inhibitor (CDKI) mutation</li><li>• correct</li><li>• Option D: Tumors are aggressive and bilateral in nature - This is generally true for MEN syndromes, where tumors can be aggressive and often present bilaterally, especially in the case of pheochromocytomas in MEN 2.</li><li>• Option D: Tumors are aggressive and bilateral in nature</li><li>• true</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ MEN syndromes are characterized by the early onset of tumors in multiple endocrine glands, with familial autosomal dominant inheritance . MEN 2B , sometimes referred to as MEN 3 , includes mucosal neuromas . MEN 4 involves CDKI mutations , and MEN syndromes often feature aggressive and bilateral tumors . MEN syndromes are not more common at an older age; they usually present in younger individuals, often before the age of 40.</li><li>➤ MEN syndromes</li><li>➤ early onset of tumors in multiple endocrine glands,</li><li>➤ familial autosomal dominant inheritance</li><li>➤ MEN 2B</li><li>➤ MEN 3</li><li>➤ mucosal neuromas</li><li>➤ MEN 4</li><li>➤ CDKI mutations</li><li>➤ MEN syndromes</li><li>➤ aggressive and bilateral tumors</li><li>➤ MEN SYNDROME</li><li>➤ MEN SYNDROME</li><li>➤ Familial disorders, AD inheritance Aggressive, B/L, At younger age Associated with multiple malignancies</li><li>➤ Familial disorders, AD inheritance</li><li>➤ Aggressive, B/L, At younger age</li><li>➤ Associated with multiple malignancies</li><li>➤ MEN 1:</li><li>➤ MEN 1:</li><li>➤ MEN 1 gene coding for MENIN PROTEIN</li><li>➤ P : P ituitary tumours: Non-functional or Functional ( P rolactinoma) P : P arathyroid tumours: M/C feature of MEN 1 (80 %-100 %) due to Multiglandular hyperplasia P : P ancreatic Tumours: Non-functional or functional (Gastrinoma)</li><li>➤ P : P ituitary tumours: Non-functional or Functional ( P rolactinoma)</li><li>➤ P</li><li>➤ P</li><li>➤ P</li><li>➤ P : P arathyroid tumours: M/C feature of MEN 1 (80 %-100 %) due to Multiglandular hyperplasia</li><li>➤ P</li><li>➤ P</li><li>➤ M/C feature of MEN 1</li><li>➤ Multiglandular hyperplasia</li><li>➤ P : P ancreatic Tumours: Non-functional or functional (Gastrinoma)</li><li>➤ P</li><li>➤ P</li><li>➤ (Gastrinoma)</li><li>➤ MEN 4:</li><li>➤ MEN 4:</li><li>➤ Cyclin Dependent Kinase inhibitor mutation. Rest same as MEN 1</li><li>➤ MEN 2 SYNDROME</li><li>➤ MEN 2 SYNDROME</li><li>➤ RET Mutation:</li><li>➤ RET Mutation:</li><li>➤ Medullary Thyroid Carcinoma (90-100%) Pheochromocytoma (10-60%)</li><li>➤ Medullary Thyroid Carcinoma (90-100%)</li><li>➤ (90-100%)</li><li>➤ Pheochromocytoma (10-60%)</li><li>➤ Sub-Types: MEN2A and MEN2B/3</li><li>➤ Sub-Types:</li><li>➤ MEN2A: Also has hyperparathyroidism due to multiglandular disease.</li><li>➤ MEN2A: Also has hyperparathyroidism due to multiglandular disease.</li><li>➤ MEN2A:</li><li>➤ Prophylactic Thyroidectomy by the age of 5 year</li><li>➤ Prophylactic Thyroidectomy by the age of 5 year</li><li>➤ MEN 2B/3:</li><li>➤ MEN 2B/3:</li><li>➤ Also has ‘MMM’ : M arfanoid Habitus, M ucosal Neuromas, M ega colon /Hirschsprung: Prophylactic Thyroidectomy by the age of 1 year</li><li>➤ ‘MMM’</li><li>➤ M</li><li>➤ M</li><li>➤ M</li><li>➤ Prophylactic Thyroidectomy by the age of 1 year</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 882-883</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 882-883</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the true statement about medullary thyroid cancers?", "options": [{"label": "A", "text": "Seen in MEN 1 syndrome", "correct": false}, {"label": "B", "text": "Tumor shows warm modularity on thyroid scan", "correct": false}, {"label": "C", "text": "Diarrhea is commonly seen due to serotonin secretion", "correct": false}, {"label": "D", "text": "Familial variant is multifocal and bilateral", "correct": true}], "correct_answer": "D. Familial variant is multifocal and bilateral", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Familial variant is multifocal and bilateral</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Seen in MEN 1 syndrome - This statement is false. Medullary thyroid cancer (MTC) is not seen in MEN 1 syndrome ; instead, it is a characteristic of MEN 2 syndrome .</li><li>• Option A: Seen in MEN 1 syndrome</li><li>• Medullary thyroid cancer</li><li>• not seen in MEN 1 syndrome</li><li>• MEN 2 syndrome</li><li>• Option B: Tumor shows warm modularity on thyroid scan - This is typically not true for MTC . Thyroid scans , which often use radioiodine , typically do not show uptake in MTC because the C cells do not absorb iodine. These tumors are often \"cold\" nodules on the scan.</li><li>• Option B:</li><li>• Tumor shows warm modularity on thyroid scan</li><li>• not true for MTC</li><li>• Thyroid scans</li><li>• use radioiodine</li><li>• do not show uptake in MTC</li><li>• Option C: Diarrhea is commonly seen due to serotonin secretion - While diarrhea is a symptom of MTC , it is not common (Seen in &lt;30%).</li><li>• Option C:</li><li>• Diarrhea is commonly seen due to serotonin secretion</li><li>• diarrhea is a symptom of MTC</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The familial variant of medullary thyroid cancer is often multifocal and bilateral, associated with MEN 2 syndrome, and tends to present at a younger age compared to sporadic cases.</li><li>➤ Medullary thyroid cancers are tumours of the parafollicular (C cells) derived from the neural crest that are not unlike those of a carcinoid tumour. High levels of serum calcitonin and carcinoembryonic antigen are produced . Calcitonin levels fall after resection and rise again with recurrence, making it a valuable tumour marker in the follow-up of patients with this disease. Diarrhea is a feature in 30% of cases and this may be due to 5-hydroxytryptamine or prostaglandins produced by the tumour cells. Medullary carcinoma may occur in combination with adrenal phaeochromocytoma and hyperparathyroidism (usually due to hyperplasia) in the syndrome known as multiple endocrine neoplasia type 2A (MEN-2A). The familial form of the disease frequently affects children and young adults, whereas the sporadic cases occur at any age with no sex predominance. The highest risk mutations are associated with early-onset disease and prophylactic total thyroidectomy is recommended during childhood.</li><li>➤ Medullary thyroid cancers are tumours of the parafollicular (C cells) derived from the neural crest that are not unlike those of a carcinoid tumour.</li><li>➤ parafollicular (C cells)</li><li>➤ High levels of serum calcitonin and carcinoembryonic antigen are produced . Calcitonin levels fall after resection and rise again with recurrence, making it a valuable tumour marker in the follow-up of patients with this disease.</li><li>➤ High levels of serum calcitonin and carcinoembryonic antigen are produced</li><li>➤ Diarrhea is a feature in 30% of cases and this may be due to 5-hydroxytryptamine or prostaglandins produced by the tumour cells.</li><li>➤ Medullary carcinoma may occur in combination with adrenal phaeochromocytoma and hyperparathyroidism (usually due to hyperplasia) in the syndrome known as multiple endocrine neoplasia type 2A (MEN-2A).</li><li>➤ multiple endocrine neoplasia type 2A (MEN-2A).</li><li>➤ The familial form of the disease frequently affects children and young adults, whereas the sporadic cases occur at any age with no sex predominance.</li><li>➤ The highest risk mutations are associated with early-onset disease and prophylactic total thyroidectomy is recommended during childhood.</li><li>➤ The highest risk mutations are associated with early-onset disease and prophylactic total thyroidectomy is recommended during childhood.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 870-871</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 870-871</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the incorrect statement about MEN syndrome?", "options": [{"label": "A", "text": "Autosomal dominant inheritance", "correct": false}, {"label": "B", "text": "Hyperparathyroidism is seen in MEN 1 and MEN 2B", "correct": true}, {"label": "C", "text": "Gastrinoma is the most common functional endocrine tumor of pancreas in MEN 1", "correct": false}, {"label": "D", "text": "Pheochromocytoma is seen in both MEN 2A and 2B", "correct": false}], "correct_answer": "B. Hyperparathyroidism is seen in MEN 1 and MEN 2B", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Hyperparathyroidism is seen in MEN 1 and MEN 2B</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Autosomal dominant inheritance - This is correct . MEN syndromes are inherited in an autosomal dominant pattern.</li><li>• Option A:</li><li>• Autosomal dominant inheritance</li><li>• correct</li><li>• Option C: Gastrinoma is the most common functional endocrine tumor of the pancreas in MEN 1 - This is true . Gastrinomas are the most common functional pancreatic endocrine tumor in MEN 1, often leading to Zollinger-Ellison syndrome.</li><li>• Option C:</li><li>• Gastrinoma is the most common functional endocrine tumor of the pancreas in MEN 1</li><li>• true</li><li>• Option D: Pheochromocytoma is seen in both MEN 2A and 2B - This is correct . Pheochromocytoma is a feature of both MEN 2A and MEN 2B syndromes.</li><li>• Option D:</li><li>• Pheochromocytoma is seen in both MEN 2A and 2B</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Identify that hyperparathyroidism is a feature of MEN 1 and MEN 2A , not MEN 2B . MEN syndromes are inherited in an autosomal dominant pattern , and specific tumors are associated with each subtype.</li><li>➤ hyperparathyroidism is a feature of MEN 1</li><li>➤ MEN 2A</li><li>➤ not MEN 2B</li><li>➤ MEN syndromes</li><li>➤ inherited in an autosomal dominant pattern</li><li>➤ MEN (Autosomal dominant) Syndrome:</li><li>➤ MEN (Autosomal dominant) Syndrome:</li><li>➤ MEN 1: Pituitary + Parathyroid + Pancreas MEN 2A: MTC + Pheochromocytoma + Parathyroid hyperplasia MEN 2B: MTC + Pheochromocytoma + Mucosal neuromas</li><li>➤ MEN 1: Pituitary + Parathyroid + Pancreas</li><li>➤ MEN 1:</li><li>➤ MEN 2A: MTC + Pheochromocytoma + Parathyroid hyperplasia</li><li>➤ MEN 2A:</li><li>➤ MEN 2B: MTC + Pheochromocytoma + Mucosal neuromas</li><li>➤ MEN 2B:</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 882</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 882</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the most common tumour arising from adrenal gland?", "options": [{"label": "A", "text": "Non-functional adenoma", "correct": true}, {"label": "B", "text": "Cushing’s adenoma", "correct": false}, {"label": "C", "text": "Pheochromocytoma", "correct": false}, {"label": "D", "text": "Metastasis", "correct": false}], "correct_answer": "A. Non-functional adenoma", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Non-functional adenoma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Cushing’s adenoma - These are functional adenomas that produce cortisol , leading to Cushing’s syndrome . They are less common than non-functional adenomas.</li><li>• Option B:</li><li>• Cushing’s adenoma</li><li>• functional adenomas</li><li>• produce cortisol</li><li>• Cushing’s syndrome</li><li>• Option C: Pheochromocytoma - This is a rare tumor that arises from the chromaffin cells of the adrenal medulla and produces catecholamines , leading to episodes of hypertension , palpitations, and headaches . They are less common than non-functional adenomas.</li><li>• Option C:</li><li>• Pheochromocytoma</li><li>• rare tumor that arises from the chromaffin cells</li><li>• adrenal medulla</li><li>• produces catecholamines</li><li>• leading to episodes of hypertension</li><li>• palpitations, and headaches</li><li>• Option D: Metastasis - While the adrenal glands are a common site for metastasis from other primary tumors , such as lung and breast cancer, this is not a primary tumor of the adrenal gland itself.</li><li>• Option D:</li><li>• Metastasis</li><li>• adrenal glands</li><li>• common site for metastasis</li><li>• primary tumors</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most common tumor arising from the adrenal gland is the non-functional adenoma , often discovered incidentally on imaging studies.</li><li>➤ common tumor arising from the adrenal gland</li><li>➤ non-functional adenoma</li><li>➤ An asymptomatic adrenal mass detected on imaging not performed for suspected adrenal disease is termed an incidentaloma . The types include benign and malignant tumours of the cortex and medulla or of extra-adrenal origin. These tumours can be either non-functioning (silent) or functioning (secreting excess hormones). Radiological features suspicious of adrenal malignancy Diameter &gt; 40 mm and &gt; 10 HU density Contrast-enhanced washout CT MRI chemical shift: no change in signal intensity on out-of-phase imaging FDG-PET: positive uptake</li><li>➤ An asymptomatic adrenal mass detected on imaging not performed for suspected adrenal disease is termed an incidentaloma .</li><li>➤ incidentaloma</li><li>➤ The types include benign and malignant tumours of the cortex and medulla or of extra-adrenal origin.</li><li>➤ These tumours can be either non-functioning (silent) or functioning (secreting excess hormones).</li><li>➤ Radiological features suspicious of adrenal malignancy Diameter &gt; 40 mm and &gt; 10 HU density Contrast-enhanced washout CT MRI chemical shift: no change in signal intensity on out-of-phase imaging FDG-PET: positive uptake</li><li>➤ Radiological features suspicious of adrenal malignancy</li><li>➤ Diameter &gt; 40 mm and &gt; 10 HU density Contrast-enhanced washout CT MRI chemical shift: no change in signal intensity on out-of-phase imaging FDG-PET: positive uptake</li><li>➤ Diameter &gt; 40 mm and &gt; 10 HU density</li><li>➤ Contrast-enhanced washout CT</li><li>➤ MRI chemical shift: no change in signal intensity on out-of-phase imaging</li><li>➤ MRI chemical shift:</li><li>➤ FDG-PET: positive uptake</li><li>➤ FDG-PET:</li><li>➤ Management:</li><li>➤ Management:</li><li>➤ All patients should be discussed in a multidisciplinary setting. Adrenalectomy is the standard of care for patients with unilateral tumours causing hormone excess (functional adenomas). Adrenalectomy is recommended for all tumours &gt; 40 mm in diameter , tumours showing imaging characteristics of malignancy and tumours showing significant growth. Laparoscopic adrenalectomy is recommended for unilateral adrenal masses with radiological findings suspicious of malignancy and a diameter &lt; 6 cm without local invasion. Small (&lt; 40mm) benign non-functioning tumours do not require surgery, but patients should undergo a follow-up CT/MRI at 6 months.</li><li>➤ All patients should be discussed in a multidisciplinary setting.</li><li>➤ Adrenalectomy is the standard of care for patients with unilateral tumours causing hormone excess (functional adenomas).</li><li>➤ Adrenalectomy is recommended for all tumours &gt; 40 mm in diameter , tumours showing imaging characteristics of malignancy and tumours showing significant growth.</li><li>➤ Adrenalectomy is recommended for all tumours &gt; 40 mm in diameter</li><li>➤ Laparoscopic adrenalectomy is recommended for unilateral adrenal masses with radiological findings suspicious of malignancy and a diameter &lt; 6 cm without local invasion.</li><li>➤ Small (&lt; 40mm) benign non-functioning tumours do not require surgery, but patients should undergo a follow-up CT/MRI at 6 months.</li><li>➤ Small (&lt; 40mm) benign non-functioning tumours do not require surgery, but patients should undergo a follow-up CT/MRI at 6 months.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 890</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 890</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "What is preferred investigation modality for localisation of pheochromocytoma?", "options": [{"label": "A", "text": "EUS", "correct": false}, {"label": "B", "text": "MRI", "correct": true}, {"label": "C", "text": "DOPA PET", "correct": false}, {"label": "D", "text": "MIBG Scan", "correct": false}], "correct_answer": "B. MRI", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) MRI</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: EUS (Endoscopic Ultrasound) - EUS is not typically used for the localization of pheochromocytoma . It is more commonly used for gastrointestinal lesions and for assessing the pancreas.</li><li>• Option A:</li><li>• EUS (Endoscopic Ultrasound)</li><li>• not typically used for the localization of pheochromocytoma</li><li>• Option C: DOPA PET (Dihydroxyphenylalanine Positron Emission Tomography) - While DOPA PET scans can be very sensitive for detecting pheochromocytoma, especially when other imaging is inconclusive , they are not the first-line investigation due to cost and availability.</li><li>• Option C:</li><li>• DOPA PET (Dihydroxyphenylalanine Positron Emission Tomography)</li><li>• DOPA PET scans</li><li>• very sensitive for detecting pheochromocytoma,</li><li>• imaging is inconclusive</li><li>• Option D: MIBG Scan (Metaiodobenzylguanidine Scan) - MIBG scans are highly specific for pheochromocytoma , particularly for extra-adrenal and metastatic disease . However, they are usually reserved for when initial imaging with CT or MRI is inconclusive.</li><li>• Option D:</li><li>• MIBG Scan (Metaiodobenzylguanidine Scan)</li><li>• highly specific for pheochromocytoma</li><li>• extra-adrenal and metastatic disease</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The preferred initial imaging modality for localizing pheochromocytoma is MRI, due to its detailed soft tissue imaging capabilities, which are beneficial for assessing tumor size and the risk of malignancy.</li><li>➤ Once a biochemical diagnosis is established, imaging by CT or MRI is undertaken to determine tumour location and assess its size and risk of malignancy. Size is not a predictor of malignancy for pheochromocytoma. Malignant Pheochromocytoma and Paragangliomas (PPGLs) are diagnosed by the presence of local invasion or metastatic disease . Tumours appear vascular and frequently possess cystic areas or central necrosis. If initial imaging is negative or reveals extra-adrenal disease, functional investigation with 123I-MIBG (meta-iodo benzyl guanidine; 80–90% sensitive) or 111 In-octreotide scanning (50–70% sensitive) is undertaken. Routine use is not advocated in well-localised adrenal lesions. More recently, 6-[18F] Fluoro-dopamine PET scanning has shown promise, particularly in the setting of PGLs, where conventional imaging and MIBG scanning are negative.</li><li>➤ Once a biochemical diagnosis is established, imaging by CT or MRI is undertaken to determine tumour location and assess its size and risk of malignancy. Size is not a predictor of malignancy for pheochromocytoma.</li><li>➤ determine tumour location and assess its size and risk of malignancy.</li><li>➤ Malignant Pheochromocytoma and Paragangliomas (PPGLs) are diagnosed by the presence of local invasion or metastatic disease . Tumours appear vascular and frequently possess cystic areas or central necrosis.</li><li>➤ Malignant Pheochromocytoma and Paragangliomas (PPGLs) are diagnosed by the presence of local invasion or metastatic disease</li><li>➤ If initial imaging is negative or reveals extra-adrenal disease, functional investigation with 123I-MIBG (meta-iodo benzyl guanidine; 80–90% sensitive) or 111 In-octreotide scanning (50–70% sensitive) is undertaken. Routine use is not advocated in well-localised adrenal lesions.</li><li>➤ functional investigation with 123I-MIBG</li><li>➤ or 111 In-octreotide scanning</li><li>➤ Routine use is not advocated in well-localised adrenal lesions.</li><li>➤ More recently, 6-[18F] Fluoro-dopamine PET scanning has shown promise, particularly in the setting of PGLs, where conventional imaging and MIBG scanning are negative.</li><li>➤ 6-[18F] Fluoro-dopamine PET scanning</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 900-901</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 900-901</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 55 years old patient presented with severe headache, palpitations and sweating. On CECT abdomen, an adrenal tumour was detected. Which of the following findings is unlikely to be seen in this case?", "options": [{"label": "A", "text": "Elevated plasma catecholamines", "correct": false}, {"label": "B", "text": "Plasma dopamine levels positive", "correct": false}, {"label": "C", "text": "Decreased 24 hours’ urinary excretion of fractionated metanephrine", "correct": true}, {"label": "D", "text": "Elevated urinary catecholamines", "correct": false}], "correct_answer": "C. Decreased 24 hours’ urinary excretion of fractionated metanephrine", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Decreased 24 hours’ urinary excretion of fractionated metanephrine</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Elevated plasma catecholamines - This would likely be seen in a patient with a pheochromocytoma , as these tumors secrete high levels of catecholamines, leading to the classic triad of symptoms.</li><li>• Option A:</li><li>• Elevated plasma catecholamines</li><li>• seen in a patient with a pheochromocytoma</li><li>• Option B: Plasma dopamine levels positive - Elevated plasma dopamine can be seen in certain cases of pheochromocytomas , especially malignant ones , as it can be a marker of tumor burden.</li><li>• Option B:</li><li>• Plasma dopamine levels positive</li><li>• Elevated plasma dopamine</li><li>• seen in certain cases of pheochromocytomas</li><li>• malignant ones</li><li>• Option D: Elevated urinary catecholamines - Elevated urinary catecholamines would be expected in a patient with a pheochromocytoma , as the tumor secretes catecholamines that are metabolized and excreted in the urine.</li><li>• Option D:</li><li>• Elevated urinary catecholamines</li><li>• Elevated urinary catecholamines</li><li>• expected in a patient with a pheochromocytoma</li><li>• tumor secretes catecholamines</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In the setting of an adrenal tumor and symptoms of headache, palpitations, and sweating, increased levels of urinary metanephrines are typical and help confirm the diagnosis of pheochromocytoma.</li><li>➤ adrenal tumor and symptoms of headache, palpitations, and sweating, increased levels of urinary metanephrines</li><li>➤ Increased 24 hours’ urinary excretion of fractionated metanephrine seen. The diagnosis of Pheochromocytoma is confirmed by elevated catecholamine metabolites (metanephrine) in plasma and/or raised 24-hour urinary excretion of fractionated metanephrines. Measurement of plasma and urinary metanephrines is more sensitive (99% and 97%, respectively) than plasma and urinary catecholamine measurement (86% and 84%, respectively). Measurements of one or more of these substances that are four times greater than the upper limit of the reference range are 100% diagnostic. Plasma dopamine can be regarded as a marker of tumour burden in malignant PPGLs.</li><li>➤ Increased 24 hours’ urinary excretion of fractionated metanephrine seen.</li><li>➤ The diagnosis of Pheochromocytoma is confirmed by elevated catecholamine metabolites (metanephrine) in plasma and/or raised 24-hour urinary excretion of fractionated metanephrines.</li><li>➤ Measurement of plasma and urinary metanephrines is more sensitive (99% and 97%, respectively) than plasma and urinary catecholamine measurement (86% and 84%, respectively).</li><li>➤ Measurement of plasma and urinary metanephrines is more sensitive</li><li>➤ Measurements of one or more of these substances that are four times greater than the upper limit of the reference range are 100% diagnostic.</li><li>➤ Plasma dopamine can be regarded as a marker of tumour burden in malignant PPGLs.</li><li>➤ Plasma dopamine can be regarded as a marker of tumour burden in malignant PPGLs.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 900</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 900</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following does not fit into the 10% rule of pheochromocytomas?", "options": [{"label": "A", "text": "10% are unilateral", "correct": true}, {"label": "B", "text": "10% are inherited", "correct": false}, {"label": "C", "text": "10% are extra adrenal", "correct": false}, {"label": "D", "text": "10% are malignant", "correct": false}], "correct_answer": "A. 10% are unilateral", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) 10% are unilateral</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The \"10% rule\" for pheochromocytomas suggests that approximately 10% are bilateral , inherited , extra-adrenal, malignant, and occur in children , which means that stating 10% are unilateral does not fit this rule .</li><li>➤ \"10% rule\"</li><li>➤ pheochromocytomas</li><li>➤ approximately 10% are bilateral</li><li>➤ inherited</li><li>➤ extra-adrenal, malignant,</li><li>➤ occur in children</li><li>➤ 10% are unilateral does not fit this rule</li><li>➤ Rule of 10% for pheochromocytomas:</li><li>➤ 10% are bilateral 10% inherited 10% extra-adrenal (Organ of Zuckerkandl) 10% malignant 10% occur in children.</li><li>➤ 10% are bilateral</li><li>➤ 10% inherited</li><li>➤ 10% extra-adrenal (Organ of Zuckerkandl)</li><li>➤ 10% malignant</li><li>➤ 10% occur in children.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 899-900.</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 899-900.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}]; if (!Array.isArray(questions) || questions.length === 0) { throw new Error("Questions data is empty or invalid"); } debugLog(`Successfully parsed ${questions.length} questions`); } catch (e) { console.error("Failed to parse questions_json:", e); document.getElementById('error-message').innerHTML = "Error loading quiz data. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('start-test').disabled = true; // Fallback to sample questions for testing questions = [ { text: "What is 2 + 2?", options: [ { label: "A", text: "3", correct: false }, { label: "B", text: "4", correct: true }, { label: "C", text: "5", correct: false }, { label: "D", text: "6", correct: false } ], correct_answer: "B. 4", question_images: [], explanation_images: [], explanation: "<p>2 + 2 = 4</p><p>@dams_new_robot</p>", bot: "@dams_new_robot", audio: "", video: "" } ]; debugLog("Loaded fallback questions"); } // Quiz state let currentQuestion = 0; let answers = new Array(questions.length).fill(null); let markedForReview = new Array(questions.length).fill(false); let timeRemaining = 111 * 60; // Duration in seconds let timerInterval = null; const quizId = `{title.replace(/\s+/g, '_').toLowerCase()}`; // Unique ID for local storage // Load saved progress function loadProgress() { try { debugLog("Loading progress from localStorage"); const saved = localStorage.getItem(`quiz_${quizId}`); if (saved) { const { savedAnswers, savedMarked, savedTime } = JSON.parse(saved); answers = savedAnswers || answers; markedForReview = savedMarked || markedForReview; timeRemaining = savedTime !== undefined ? savedTime : timeRemaining; debugLog("Progress loaded successfully"); } else { debugLog("No saved progress found"); } } catch (e) { console.error("Error loading progress:", e); debugLog("Failed to load progress: " + e.message); } } // Save progress function saveProgress() { try { debugLog("Saving progress to localStorage"); localStorage.setItem(`quiz_${quizId}`, JSON.stringify({ savedAnswers: answers, savedMarked: markedForReview, savedTime: timeRemaining })); debugLog("Progress saved successfully"); } catch (e) { console.error("Error saving progress:", e); debugLog("Failed to save progress: " + e.message); } } // Initialize quiz function initQuiz() { try { debugLog("Initializing quiz"); loadProgress(); const startButton = document.getElementById('start-test'); if (!startButton) { throw new Error("Start test button not found"); } startButton.addEventListener('click', startQuiz); debugLog("Start test button listener attached"); document.getElementById('previous-btn').addEventListener('click', showPreviousQuestion); document.getElementById('next-btn').addEventListener('click', showNextQuestion); document.getElementById('mark-review').addEventListener('click', toggleMarkForReview); document.getElementById('nav-toggle').addEventListener('click', toggleNavPanel); document.getElementById('submit-test').addEventListener('click', showSubmitModal); document.getElementById('continue-test').addEventListener('click', closeExitModal); document.getElementById('exit-test').addEventListener('click', () => { debugLog("Exiting test"); localStorage.removeItem(`quiz_${quizId}`); window.location.reload(); }); document.getElementById('cancel-submit').addEventListener('click', closeSubmitModal); document.getElementById('confirm-submit').addEventListener('click', submitTest); document.getElementById('take-again').addEventListener('click', () => { debugLog("Restarting test"); localStorage.removeItem(`quiz_${quizId}`); window.location.reload(); }); document.getElementById('review-test').addEventListener('click', () => showResults(currentResultQuestion)); document.getElementById('close-nav').addEventListener('click', toggleNavPanel); document.getElementById('theme-toggle').addEventListener('click', toggleTheme); document.getElementById('nav-filter').addEventListener('change', updateNavPanel); document.getElementById('prev-result').addEventListener('click', showPreviousResult); document.getElementById('next-result').addEventListener('click', showNextResult); document.getElementById('results-nav-toggle').addEventListener('click', toggleResultsNavPanel); document.getElementById('close-results-nav').addEventListener('click', toggleResultsNavPanel); document.getElementById('results-nav-filter').addEventListener('change', updateResultsNavPanel); debugLog("Quiz initialized successfully"); } catch (e) { console.error("Failed to initialize quiz:", e); debugLog("Failed to initialize quiz: " + e.message); document.getElementById('error-message').innerHTML = "Error initializing quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('start-test').disabled = true; } } // Start quiz function startQuiz() { try { debugLog("Starting quiz"); document.getElementById('instructions').classList.add('hidden'); document.getElementById('quiz').classList.remove('hidden'); showQuestion(currentQuestion); startTimer(); updateNavPanel(); debugLog("Quiz started successfully"); } catch (e) { console.error("Error starting quiz:", e); debugLog("Failed to start quiz: " + e.message); document.getElementById('error-message').innerHTML = "Error starting quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('quiz').classList.add('hidden'); document.getElementById('instructions').classList.remove('hidden'); } } // Show question function showQuestion(index) { try { debugLog(`Showing question ${index + 1}`); currentQuestion = index; const q = questions[index]; if (!q) { throw new Error(`Question ${index} is undefined`); } document.getElementById('question-number').innerHTML = `Question <span>${index + 1}</span> of ${questions.length}`; document.getElementById('question-text').innerHTML = q.text || "No question text available"; const imagesDiv = document.getElementById('question-images'); imagesDiv.innerHTML = q.question_images && q.question_images.length > 0 ? q.question_images.map(url => `<img src="${url}" alt="Question Image" class="max-w-full h-auto rounded-lg">`).join('') : ''; const optionsDiv = document.getElementById('options'); optionsDiv.innerHTML = q.options && q.options.length > 0 ? q.options.map(opt => ` <button class="option-btn w-full text-left p-3 border rounded-lg ${answers[index] === opt.label ? 'selected' : ''}" onclick="selectOption(${index}, '${opt.label}')" aria-label="Option ${opt.label}: ${opt.text}"> ${opt.label}. ${opt.text} </button> `).join('') : '<p class="text-red-500">No options available</p>'; document.getElementById('previous-btn').disabled = index === 0; document.getElementById('next-btn').disabled = index === questions.length - 1; document.getElementById('mark-review').classList.toggle('marked', markedForReview[index]); updateProgressBar(); saveProgress(); window.scrollTo({ top: 0, behavior: 'smooth' }); debugLog(`Question ${index + 1} displayed successfully`); } catch (e) { console.error("Error displaying question:", e); debugLog("Failed to display question: " + e.message); } } // Select option function selectOption(index, label) { try { debugLog(`Selecting option ${label} for question ${index + 1}`); answers[index] = label; const optionsDiv = document.getElementById('options'); const optionButtons = optionsDiv.querySelectorAll('.option-btn'); optionButtons.forEach(btn => { const btnLabel = btn.textContent.trim().split('.')[0]; btn.classList.toggle('selected', btnLabel === label); }); updateNavPanel(); saveProgress(); debugLog(`Option ${label} selected for question ${index + 1}`); } catch (e) { console.error("Error selecting option:", e); debugLog("Failed to select option: " + e.message); } } // Toggle mark for review function toggleMarkForReview() { try { debugLog(`Toggling mark for review on question ${currentQuestion + 1}`); markedForReview[currentQuestion] = !markedForReview[currentQuestion]; document.getElementById('mark-review').classList.toggle('marked', markedForReview[currentQuestion]); updateNavPanel(); saveProgress(); debugLog(`Mark for review toggled for question ${currentQuestion + 1}`); } catch (e) { console.error("Error marking for review:", e); debugLog("Failed to mark for review: " + e.message); } } // Navigate to previous question function showPreviousQuestion() { try { debugLog(`Navigating to previous question from ${currentQuestion + 1}`); if (currentQuestion > 0) { currentQuestion--; showQuestion(currentQuestion); } } catch (e) { console.error("Error navigating to previous question:", e); debugLog("Failed to navigate to previous question: " + e.message); } } // Navigate to next question function showNextQuestion() { try { debugLog(`Navigating to next question from ${currentQuestion + 1}`); if (currentQuestion < questions.length - 1) { currentQuestion++; showQuestion(currentQuestion); } } catch (e) { console.error("Error navigating to next question:", e); debugLog("Failed to navigate to next question: " + e.message); } } // Handle question navigation click function handleQuestionNavClick(index) { try { debugLog(`Navigating to question ${index + 1} via nav panel`); showQuestion(index); toggleNavPanel(); } catch (e) { console.error("Error handling navigation click:", e); debugLog("Failed to navigate via nav panel: " + e.message); } } // Start timer function startTimer() { try { debugLog("Starting timer"); timerInterval = setInterval(() => { if (timeRemaining <= 0) { debugLog("Timer expired, submitting test"); clearInterval(timerInterval); submitTest(); } else { timeRemaining--; const minutes = Math.floor(timeRemaining / 60); const seconds = timeRemaining % 60; document.getElementById('timer').innerHTML = `Time Remaining: <span>${minutes.toString().padStart(2, '0')}:${seconds.toString().padStart(2, '0')}</span>`; saveProgress(); } }, 1000); debugLog("Timer started successfully"); } catch (e) { console.error("Error starting timer:", e); debugLog("Failed to start timer: " + e.message); } } // Update progress bar function updateProgressBar() { try { debugLog("Updating progress bar"); const progress = ((currentQuestion + 1) / questions.length) * 100; document.getElementById('progress-bar').style.width = `${progress}%`; debugLog("Progress bar updated"); } catch (e) { console.error("Error updating progress bar:", e); debugLog("Failed to update progress bar: " + e.message); } } // Update quiz navigation panel function updateNavPanel() { try { debugLog("Updating quiz navigation panel"); const filter = document.getElementById('nav-filter').value; const navGrid = document.getElementById('nav-grid'); navGrid.innerHTML = questions.map((_, i) => { if (filter === 'answered' && !answers[i]) return ''; if (filter === 'unanswered' && answers[i]) return ''; if (filter === 'marked' && !markedForReview[i]) return ''; return ` <button class="question-nav-btn ${answers[i] ? 'answered' : 'unanswered'} ${markedForReview[i] ? 'marked-nav' : ''}" onclick="handleQuestionNavClick(${i})" aria-label="Go to Question ${i + 1}"> ${i + 1} </button> `; }).join(''); debugLog("Quiz navigation panel updated"); } catch (e) { console.error("Error updating quiz navigation panel:", e); debugLog("Failed to update quiz navigation panel: " + e.message); } } // Update results navigation panel function updateResultsNavPanel() { try { debugLog("Updating results navigation panel"); const filter = document.getElementById('results-nav-filter').value; const navGrid = document.getElementById('results-nav-grid'); navGrid.innerHTML = questions.map((_, i) => { if (filter === 'answered' && !answers[i]) return ''; if (filter === 'unanswered' && answers[i]) return ''; if (filter === 'marked' && !markedForReview[i]) return ''; return ` <button class="result-nav-btn-grid ${answers[i] ? 'answered' : 'unanswered'} ${markedForReview[i] ? 'marked-nav' : ''}" onclick="handleResultNavClick(${i})" aria-label="Go to Result for Question ${i + 1}"> ${i + 1} </button> `; }).join(''); debugLog("Results navigation panel updated"); } catch (e) { console.error("Error updating results navigation panel:", e); debugLog("Failed to update results navigation panel: " + e.message); } } // Toggle quiz navigation panel function toggleNavPanel() { try { debugLog("Toggling quiz navigation panel"); const navPanel = document.getElementById('nav-panel'); navPanel.classList.toggle('hidden'); debugLog("Quiz navigation panel toggled"); } catch (e) { console.error("Error toggling quiz navigation panel:", e); debugLog("Failed to toggle quiz navigation panel: " + e.message); } } // Toggle results navigation panel function toggleResultsNavPanel() { try { debugLog("Toggling results navigation panel"); const resultsNavPanel = document.getElementById('results-nav-panel'); resultsNavPanel.classList.toggle('hidden'); if (!resultsNavPanel.classList.contains('hidden')) { updateResultsNavPanel(); } debugLog("Results navigation panel toggled"); } catch (e) { console.error("Error toggling results navigation panel:", e); debugLog("Failed to toggle results navigation panel: " + e.message); } } // Handle result navigation click function handleResultNavClick(index) { try { debugLog(`Navigating to result for question ${index + 1} via nav panel`); showResults(index); toggleResultsNavPanel(); } catch (e) { console.error("Error handling result navigation click:", e); debugLog("Failed to navigate to result: " + e.message); } } // Show submit modal function showSubmitModal() { try { debugLog("Showing submit modal"); const attempted = answers.filter(a => a !== null).length; document.getElementById('attempted-count').textContent = attempted; document.getElementById('unattempted-count').textContent = questions.length - attempted; document.getElementById('submit-modal').classList.remove('hidden'); debugLog("Submit modal displayed"); } catch (e) { console.error("Error showing submit modal:", e); debugLog("Failed to show submit modal: " + e.message); } } // Close submit modal function closeSubmitModal() { try { debugLog("Closing submit modal"); document.getElementById('submit-modal').classList.add('hidden'); debugLog("Submit modal closed"); } catch (e) { console.error("Error closing submit modal:", e); debugLog("Failed to close submit modal: " + e.message); } } // Close exit modal function closeExitModal() { try { debugLog("Closing exit modal"); document.getElementById('exit-modal').classList.add('hidden'); debugLog("Exit modal closed"); } catch (e) { console.error("Error closing exit modal:", e); debugLog("Failed to close exit modal: " + e.message); } } // Submit test function submitTest() { try { debugLog("Submitting test"); clearInterval(timerInterval); document.getElementById('quiz').classList.add('hidden'); document.getElementById('submit-modal').classList.add('hidden'); document.getElementById('results').classList.remove('hidden'); showResults(0); // Start with first question // Trigger confetti animation confetti({ particleCount: 100, spread: 70, origin: { y: 0.6 } }); localStorage.removeItem(`quiz_${quizId}`); debugLog("Test submitted successfully"); } catch (e) { console.error("Error submitting test:", e); debugLog("Failed to submit test: " + e.message); } } // Show result for a single question function showResults(index) { try { debugLog(`Showing result for question ${index + 1}`); currentResultQuestion = index; let correct = 0, wrong = 0, unanswered = 0, marked = 0; answers.forEach((answer, i) => { const isCorrect = answer && questions[i].options.find(opt => opt.label === answer)?.correct; if (answer === null) unanswered++; else if (isCorrect) correct++; else wrong++; if (markedForReview[i]) marked++; }); const q = questions[index]; if (!q) { throw new Error(`Question ${index} is undefined`); } const userAnswer = answers[index]; const isCorrect = userAnswer && q.options.find(opt => opt.label === userAnswer)?.correct; const resultsContent = document.getElementById('results-content'); resultsContent.innerHTML = ` <div class="border p-4 rounded-lg ${isCorrect ? 'bg-green-50' : userAnswer ? 'bg-red-50' : 'bg-gray-50'}"> <p class="font-semibold">Question ${index + 1}: ${q.text || 'No question text'}</p> ${q.question_images && q.question_images.length > 0 ? q.question_images.map(url => `<img src="${url}" alt="Question Image" class="max-w-full h-auto rounded-lg my-2">`).join('') : ''} <p><strong>Your Answer:</strong> ${userAnswer ? `${userAnswer}. ${q.options.find(opt => opt.label === userAnswer)?.text || 'Invalid option'}` : 'Unanswered'}</p> <p><strong>Correct Answer:</strong> ${q.correct_answer || 'Unknown'}</p> <div class="mt-2">${q.explanation || 'No explanation available'}</div> ${q.explanation_images && q.explanation_images.length > 0 ? q.explanation_images.map(url => `<img src="${url}" alt="Explanation Image" class="max-w-full h-auto rounded-lg my-2">`).join('') : ''} ${q.video ? ` <button class="play-video bg-blue-500 text-white px-4 py-2 rounded-lg mt-2" onclick="loadVideo(this, '${q.video}', 'video-${index}')" aria-label="Play explanation video for Question ${index + 1}"> Play Video Explanation </button> <div id="video-${index}" class="video-container mt-2"></div> ` : '<p class="text-gray-500 mt-2">No video available</p>'} ${q.audio ? ` <button class="play-audio bg-blue-500 text-white px-4 py-2 rounded-lg mt-2" onclick="loadAudio(this, '${q.audio}', 'audio-${index}')" aria-label="Play audio explanation for Question ${index + 1}"> Play Audio Explanation </button> <div id="audio-${index}" class="audio-container mt-2"></div> ` : ''} </div> `; document.getElementById('correct-count').textContent = correct; document.getElementById('wrong-count').textContent = wrong; document.getElementById('unanswered-count').textContent = unanswered; document.getElementById('marked-count').textContent = marked; document.getElementById('result-question-number').innerHTML = `Question <span>${index + 1}</span> of ${questions.length}`; document.getElementById('prev-result').disabled = index === 0; document.getElementById('next-result').disabled = index === questions.length - 1; updateResultsNavPanel(); window.scrollTo({ top: 0, behavior: 'smooth' }); debugLog(`Result for question ${index + 1} displayed successfully`); } catch (e) { console.error("Error displaying result:", e); debugLog("Failed to display result: " + e.message); } } // Navigate to previous result function showPreviousResult() { try { debugLog(`Navigating to previous result from question ${currentResultQuestion + 1}`); if (currentResultQuestion > 0) { showResults(currentResultQuestion - 1); } } catch (e) { console.error("Error navigating to previous result:", e); debugLog("Failed to navigate to previous result: " + e.message); } } // Navigate to next result function showNextResult() { try { debugLog(`Navigating to next result from question ${currentResultQuestion + 1}`); if (currentResultQuestion < questions.length - 1) { showResults(currentResultQuestion + 1); } } catch (e) { console.error("Error navigating to next result:", e); debugLog("Failed to navigate to next result: " + e.message); } } // Lazy-load video function loadVideo(button, videoUrl, containerId) { try { debugLog(`Loading video for ${containerId}: ${videoUrl}`); if (!videoUrl) { const container = document.getElementById(containerId); container.innerHTML = `<p class="text-gray-500">No video available</p>`; button.remove(); debugLog("No video URL provided"); return; } const container = document.getElementById(containerId); container.innerHTML = ` <div class="video-loading"></div> <video controls class="w-full max-w-[600px] rounded-lg" preload="metadata" aria-label="Video explanation"> <source src="${videoUrl}" type="${videoUrl.endsWith('.m3u8') ? 'application/x-mpegURL' : 'video/mp4'}"> Your browser does not support the video tag. </video> `; container.classList.add('active'); button.remove(); // Initialize HLS.js for .m3u8 videos const video = container.querySelector('video'); if (videoUrl.endsWith('.m3u8') && Hls.isSupported()) { const hls = new Hls(); hls.loadSource(videoUrl); hls.attachMedia(video); hls.on(Hls.Events.ERROR, (event, data) => { console.error("HLS.js error:", data); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; debugLog("HLS.js error: " + JSON.stringify(data)); }); } else if (videoUrl.endsWith('.m3u8') && video.canPlayType('application/vnd.apple.mpegurl')) { video.src = videoUrl; } // Handle video load errors video.onerror = () => { console.error("Video load error for URL:", videoUrl); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; debugLog("Video load error for URL: " + videoUrl); }; // Remove loading spinner when video is ready video.onloadedmetadata = () => { container.querySelector('.video-loading').remove(); debugLog("Video loaded successfully"); }; } catch (e) { console.error("Error loading video:", e); debugLog("Failed to load video: " + e.message); const container = document.getElementById(containerId); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; } } // Lazy-load audio function loadAudio(button, audioUrl, containerId) { try { debugLog(`Loading audio for ${containerId}: ${audioUrl}`); if (!audioUrl) { const container = document.getElementById(containerId); container.innerHTML = `<p class="text-gray-500">No audio available</p>`; button.remove(); debugLog("No audio URL provided"); return; } const container = document.getElementById(containerId); container.innerHTML = ` <audio controls class="w-full max-w-[600px]" preload="metadata" aria-label="Audio explanation"> <source src="${audioUrl}" type="audio/mpeg"> Your browser does not support the audio tag. </audio> `; container.classList.add('active'); button.remove(); // Handle audio load errors const audio = container.querySelector('audio'); audio.onerror = () => { console.error("Audio load error for URL:", audioUrl); container.innerHTML = `<p class="text-red-500">Error loading audio. <a href="${audioUrl}" target="_blank" aria-label="Open audio in new tab">Open audio</a></p>`; debugLog("Audio load error for URL: " + audioUrl); }; debugLog("Audio loaded successfully"); } catch (e) { console.error("Error loading audio:", e); debugLog("Failed to load audio: " + e.message); const container = document.getElementById(containerId); container.innerHTML = `<p class="text-red-500">Error loading audio. <a href="${audioUrl}" target="_blank" aria-label="Open audio in new tab">Open audio</a></p>`; } } // Toggle dark mode function toggleTheme() { try { debugLog("Toggling theme"); document.documentElement.classList.toggle('dark'); localStorage.setItem('theme', document.documentElement.classList.contains('dark') ? 'dark' : 'light'); debugLog("Theme toggled successfully"); } catch (e) { console.error("Error toggling theme:", e); debugLog("Failed to toggle theme: " + e.message); } } // Load theme preference function loadTheme() { try { debugLog("Loading theme preference"); const theme = localStorage.getItem('theme'); if (theme === 'dark') { document.documentElement.classList.add('dark'); } debugLog("Theme loaded successfully"); } catch (e) { console.error("Error loading theme:", e); debugLog("Failed to load theme: " + e.message); } } // Initialize on DOM content loaded window.addEventListener('DOMContentLoaded', () => { try { debugLog("DOM content loaded, initializing quiz"); loadTheme(); initQuiz(); } catch (e) { console.error("Error during DOMContentLoaded:", e); debugLog("Failed to initialize on DOMContentLoaded: " + e.message); document.getElementById('error-message').innerHTML = "Error initializing quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); } }); </script> </body> </html>" frameborder="0" width="100%" height="2000px">
<div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <h2 class="text-xl font-semibold mb-4">Instructions</h2> <h4 class="text-gray-800 text-lg font-semibold mt-6 mb-4">Test Features:</h4> <ul class="space-y-3"> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Multiple choice questions with single correct answers </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Timer-based testing for realistic exam conditions </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Mark questions for review functionality </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Comprehensive results and performance analysis </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Mobile-optimized interface for learning on-the-go </li> </ul> <div class="mt-6 flex space-x-4 button-group md:flex-row flex-col"> <button class="bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="start-test">Start Test</button> </div> <div class="error-message hidden" id="error-message"></div> </div> </section> <!-- Quiz Section --> <section class="container mx-auto px-4 md:px-6 pt-4 md:pt-6 pb-1 hidden section-transition" id="quiz"> <div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <!-- Progress Bar --> <div class="w-full bg-gray-200 rounded-full h-3 mb-4"> <div class="progress-bar h-3 rounded-full" id="progress-bar" style="width: 0%"></div> </div> <!-- Question Header --> <div class="flex flex-col md:flex-row justify-between items-center mb-4"> <h2 class="text-lg font-semibold" id="question-number">Question <span>1</span> of 4</h2> <p class="text-lg font-semibold mt-2 md:mt-0" id="timer">Time Remaining: <span>00:00</span></p> </div> <!-- Question Content --> <div class="mb-6" id="question-content"> <p class="text-gray-800 mb-4" id="question-text"></p> <div class="flex flex-wrap gap-4 mb-4" id="question-images"></div> <div class="space-y-3" id="options"></div> </div> <!-- Navigation Buttons --> <div class="flex flex-col md:flex-row justify-between items-center gap-2 md:gap-4"> <div class="flex gap-2 w-full md:w-auto"> <button class="bg-[#2c5281] text-white px-4 py-3 w-full md:w-32 h-14 rounded-lg hover:bg-[#2c5281] transition" disabled="" id="previous-btn">Previous</button> <button class="bg-[#2c5281] text-white px-4 py-3 w-full md:w-32 h-14 rounded-lg hover:bg-[#2c5281] transition" id="next-btn">Next</button> </div> <div class="flex items-center gap-2"> <button class="bg-transparent text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-100 transition flex items-center gap-1" id="mark-review"> Review <svg xmlns="http://www.w3.org/2000/svg" class="h-5 w-5" viewBox="0 0 20 20" fill="currentColor"> <path d="M10 2a1 1 0 00-1 1v14l3.293-3.293a1 1 0 011.414 0L17 17V3a1 1 0 00-1-1H10z" /> </svg> </button> <button class="bg-transparent text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-100 transition flex items-center gap-1" id="nav-toggle"> Question 🧭 </button> <button class="bg-green-500 text-white px-6 py-3 w-44 h-14 rounded-lg hover:bg-green-600 transition w-full md:w-auto" id="submit-test">Submit Test</button> </div> </div> </section> <!-- Results Section --> <section class="container mx-auto px-4 md:px-6 pt-4 md:pt-6 pb-1 hidden section-transition" id="results"> <div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <h2 class="text-2xl font-semibold mb-4">Anaesthesia Machine - Results</h2> <div class="grid grid-cols-1 md:grid-cols-2 gap-4 mb-6"> <p><strong>Correct:</strong> <span id="correct-count" class="text-[#000000]">0</span></p> <p><strong>Wrong:</strong> <span id="wrong-count" class="text-[#000000]">0</span></p> <p><strong>Unanswered:</strong> <span id="unanswered-count" class="text-[#000000]-500">0</span></p> <p><strong>Marked for Review:</strong> <span id="marked-count" class="text-[#000000]">0</span></p> </div> <h3 class="text-lg font-semibold mb-4" id="result-question-number">Question <span>1</span> of 4</h3> <div class="space-y-6" id="results-content"></div> <div class="result-nav"> <button aria-label="Previous question result" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" disabled="" id="prev-result">Previous</button> <button aria-label="Toggle results navigation panel" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="results-nav-toggle">Result 🧭</button> <button aria-label="Next question result" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="next-result">Next</button> </div> <div class="mt-6 flex space-x-4 button-group md:flex-row flex-col"> <button class="bg-green-500 text-white px-6 py-2 rounded-lg hover:bg-green-600 transition" id="take-again">Take Again</button> </div> </div> </section> <!-- Exit Confirmation Modal --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 hidden" id="exit-modal" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white rounded-lg p-6 max-w-sm w-full"> <h2 class="text-xl font-semibold mb-4">Leave Test?</h2> <p class="text-gray-700 mb-4">Your progress will be lost if you leave this page. Are you sure you want to exit?</p> <div class="flex justify-end space-x-4"> <button class="bg-gray-300 text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-400 transition" id="continue-test">No, Continue</button> <button class="bg-red-500 text-white px-4 py-2 rounded-lg hover:bg-red-600 transition" id="exit-test">Yes, Exit</button> </div> </div> </div> <!-- Submit Confirmation Modal --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 hidden" id="submit-modal" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white rounded-lg p-6 max-w-sm w-full"> <h2 class="text-xl font-semibold mb-4">Confirm Submission</h2> <p class="text-gray-700 mb-2">You have attempted <span id="attempted-count">0</span> of 4 questions.</p> <p class="text-gray-700 mb-4"><span id="unattempted-count">0</span> questions are unattempted.</p> <div class="flex justify-end space-x-4"> <button class="bg-gray-300 text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-400 transition" id="cancel-submit">Cancel</button> <button class="text-white px-4 py-2 rounded-lg hover:bg-[#1a365d] transition" style="background-color: #2c5281;" id="confirm-submit">Submit Test</button> </div> </div> </div> <!-- Quiz Navigation Panel --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 z-50 nav-panel hidden overflow-y-auto" id="nav-panel" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white shadow-lg p-4 rounded-lg w-full max-w-2xl max-h-[80vh] overflow-y-auto"> <h2 class="text-lg font-semibold mb-4">Questions Navigation</h2> <div class="mb-4"> <select class="w-full p-2 border rounded-lg text-gray-700" id="nav-filter"> <option value="all">All Questions</option> <option value="answered">Answered</option> <option value="unanswered">Unanswered</option> <option value="marked">Marked for Review</option> </select> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-nav">Close</button> </div> </div> <!-- Results Navigation Panel --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 z-50 results-nav-panel hidden overflow-y-auto" id="results-nav-panel" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white shadow-lg p-4 rounded-lg w-full max-w-2xl max-h-[80vh] overflow-y-auto"> <h2 class="text-lg font-semibold mb-4">Results Navigation</h2> <div class="mb-4"> <select class="w-full p-2 border rounded-lg text-gray-700" id="results-nav-filter"> <option value="all">All Questions</option> <option value="answered">Answered</option> <option value="unanswered">Unanswered</option> <option value="marked">Marked for Review</option> </select> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="results-nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-results-nav">Close</button> </div> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="results-nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-results-nav">Close</button> </div> <!-- JavaScript Logic --> <script> // Enable debug mode for detailed logging const DEBUG_MODE = true; // Log debug messages function debugLog(message) { if (DEBUG_MODE) { console.log(`[DEBUG] ${message}`); } } // Initialize questions with error handling let questions = []; let currentResultQuestion = 0; // State for current question in results try { debugLog("Attempting to parse questions_json"); questions = [{"text": "A 35-year-old Female presented with dysphagia, regurgitation and weight loss. On barium swallow, following appearance was seen. What is the gold standard test to diagnose this condition?", "options": [{"label": "A", "text": "Upper GI endoscopy", "correct": false}, {"label": "B", "text": "CECT abdomen + thorax", "correct": false}, {"label": "C", "text": "Esophageal manometry", "correct": true}, {"label": "D", "text": "Barium swallow", "correct": false}], "correct_answer": "C. Esophageal manometry", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/01/untitled-166.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) E</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Upper GI endoscopy : It is an initial investigation in patients with dysphagia , but not the gold standard.</li><li>• Option A.</li><li>• Upper GI endoscopy</li><li>• initial investigation in patients with dysphagia</li><li>• Option B . CECT abdomen + Thorax : It is useful in diagnosis of hiatus hernia but not achalasia.</li><li>• Option B</li><li>• CECT abdomen</li><li>• + Thorax</li><li>• diagnosis of hiatus hernia</li><li>• Option D . Barium swallow : This study involves swallowing a contrast (Barium) and X rays are taken .</li><li>• Option D</li><li>• Barium swallow</li><li>• involves swallowing a contrast</li><li>• X rays are taken</li><li>• It has largely been replaced by more specific investigations like upper GI endoscopy in patients with dysphagia.</li><li>• largely been replaced by more specific investigations</li><li>• upper GI endoscopy</li><li>• Educational objectives:</li><li>• Educational objectives:</li><li>• Manometric features of achalasia cardia are as follows:</li><li>• Manometric features of achalasia cardia are as follows:</li><li>• Incomplete lower esophageal sphincter relaxation Ineffective peristalsis of the esophageal body Elevated LES pressure</li><li>• Incomplete lower esophageal sphincter relaxation</li><li>• Ineffective peristalsis of the esophageal body</li><li>• Elevated LES pressure</li><li>• Achalasia cardia is caused due to the degeneration of the neurons in the myenteric ( parasympathetic ) plexus of the esophagus . This degeneration results in the failure of relaxation of the lower esophageal sphincter (LES) on swallowing and ineffective peristalsis in the body.</li><li>• Achalasia</li><li>• cardia</li><li>• myenteric</li><li>• parasympathetic</li><li>• plexus</li><li>• esophagus</li><li>• The patients present with a classic triad of dysphagia, regurgitation, and weight loss . The dysphagia initially begins with liquid foods and then progresses to solid foods . As the food gets accumulated in the esophagus, patients may complain of halitosis. With further progression of the disease, the patients may develop pneumonia, lung abscess, etc.</li><li>• classic triad of dysphagia, regurgitation, and weight loss</li><li>• The dysphagia initially begins with liquid foods and then progresses to solid foods</li><li>• The initial diagnosis is made by endoscopy or barium swallow, which shows the presence of dilated esophagus due to the constriction of the lower esophageal sphincter (bird-beak appearance).</li><li>• It is a premalignant condition and can cause squamous cell carcinoma of the esophagus .</li><li>• It is a premalignant condition and can cause squamous cell carcinoma of the esophagus</li><li>• Ref : Bailey 28 th Ed. Page 1121-1122.</li><li>• Ref</li><li>• : Bailey 28 th Ed. Page 1121-1122.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is true about achalasia cardia?", "options": [{"label": "A", "text": "Decreased esophageal peristalsis", "correct": true}, {"label": "B", "text": "Decreased LES tone", "correct": false}, {"label": "C", "text": "Dyphagia more towards solids", "correct": false}, {"label": "D", "text": "Decreased diameter of middle esophagus", "correct": false}], "correct_answer": "A. Decreased esophageal peristalsis", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Decreased esophageal peristalsis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. False . Achalasia is associated with increased lower esophageal sphincter (LES) tone . In achalasia, the LES does not relax properly, leading to difficulty in food passage.</li><li>• Option B. False</li><li>• Achalasia</li><li>• increased lower esophageal sphincter</li><li>• tone</li><li>• Option C. False . Dysphagia (difficulty swallowing) in achalasia tends to be more pronounced with liquids initially . This is a feature of motility disorders of esophagus.</li><li>• Option C. False</li><li>• Dysphagia</li><li>• achalasia tends to be more pronounced with liquids initially</li><li>• Option D. False . Achalasia does not typically result in a decreased diameter of the middle esophagus . In fact, one of the characteristic findings in achalasia is the dilation or enlargement of the esophagus above the point of obstruction (usually at the LES). This dilation occurs because the lower esophageal sphincter fails to relax properly, leading to a buildup of food and fluids in the esophagus, which stretches and dilates it.</li><li>• Option D. False</li><li>• Achalasia does not typically result in a decreased diameter of the middle esophagus</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Manometric findings suggestive of achalasia:</li><li>• Manometric findings suggestive of achalasia:</li><li>• Abnormally elevated Integrated relaxing pressure (IRP) 100% absent peristalsis, all swallows are either failed or premature.</li><li>• Abnormally elevated Integrated relaxing pressure (IRP)</li><li>• (IRP)</li><li>• 100% absent peristalsis, all swallows are either failed or premature.</li><li>• Ref : Bailey and Love 28 th Ed. Pg 1122 Fig 66.23</li><li>• Ref</li><li>• : Bailey and Love 28 th Ed. Pg 1122 Fig 66.23</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old patient presented with dysphagia for liquid food more than solid foods. She also complains of regurgitation, halitosis and weight loss. On upper GI endoscopy, there was narrowing at the lower esophageal sphincter and dilatation of the proximal part of the esophagus. What is the definitive modality of treatment for the above condition?", "options": [{"label": "A", "text": "Endoscopic dilation", "correct": false}, {"label": "B", "text": "Heller’s myotomy", "correct": true}, {"label": "C", "text": "Dor’s fundoplication", "correct": false}, {"label": "D", "text": "Ramstead’s myotomy", "correct": false}], "correct_answer": "B. Heller’s myotomy", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/18/screenshot-2024-03-18-172706.jpg"], "explanation": "<p><strong>Ans. B)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Endoscopic Dilation : While this can provide temporary relief of symptoms , it is not considered the definitive treatment for achalasia and may need to be repeated.</li><li>• Option A. Endoscopic Dilation</li><li>• provide temporary relief of symptoms</li><li>• Option C. Dor's Fundoplication : This procedure is typically performed in the context of treating Gastroesophageal Reflux Disease (GERD) and is not the primary treatment for achalasia.</li><li>• Option C. Dor's Fundoplication</li><li>• Gastroesophageal Reflux Disease (GERD)</li><li>• Option D. Ramstead's Myotomy : Ramstedt's pyloromyotomy is a surgical procedure used to treat infantile hypertrophic pyloric stenosis , not achalasia.</li><li>• Option D. Ramstead's Myotomy</li><li>• surgical procedure used to treat infantile hypertrophic pyloric stenosis</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Treatment of achalasia cardia:</li><li>• Treatment of achalasia cardia:</li><li>• Non-surgical :</li><li>• Non-surgical</li><li>• Medications : Sublingual Nitroglycerin or oral calcium-channel blockers Endoscopic pneumatic dilatation</li><li>• Medications : Sublingual Nitroglycerin or oral calcium-channel blockers</li><li>• Medications</li><li>• Sublingual Nitroglycerin</li><li>• oral calcium-channel blockers</li><li>• Endoscopic pneumatic dilatation</li><li>• Endoscopic pneumatic dilatation</li><li>• Disadvantage: Need for frequent multiple interventions &amp; risk of esophageal perforations.</li><li>• Disadvantage:</li><li>• Botox injection</li><li>• Botox injection</li><li>• Botox injection</li><li>• Symptoms may recur in 50% of the patients within 6 months.</li><li>• Surgical - Treatment of choice</li><li>• Surgical</li><li>• Modified laparoscopic Heller myotomy is the operation of choice. The addition of a partial anti reflux procedure, such as a Toupet or Dor fundoplication, will restore a barrier to the reflux and decrease the severity of postoperative symptoms. Advantage : Definite treatment of end-stage achalasia patient Per Oral Endoscopic Myotomy (POEM) is a recently introduced, advanced natural-orifice approach for myotomy. It is preferred for Type III Achalasia (spastic type). Esophagectomy is considered in any symptomatic patient with the following: tortuous esophagus (megaoesophagus)/sigmoid esophagus.</li><li>• Modified laparoscopic Heller myotomy is the operation of choice. The addition of a partial anti reflux procedure, such as a Toupet or Dor fundoplication, will restore a barrier to the reflux and decrease the severity of postoperative symptoms. Advantage : Definite treatment of end-stage achalasia patient</li><li>• Modified laparoscopic Heller myotomy is the operation of choice.</li><li>• The addition of a partial anti reflux procedure, such as a Toupet or Dor fundoplication, will restore a barrier to the reflux and decrease the severity of postoperative symptoms. Advantage : Definite treatment of end-stage achalasia patient</li><li>• The addition of a partial anti reflux procedure, such as a Toupet or Dor fundoplication, will restore a barrier to the reflux and decrease the severity of postoperative symptoms.</li><li>• Advantage : Definite treatment of end-stage achalasia patient</li><li>• Advantage</li><li>• Per Oral Endoscopic Myotomy (POEM) is a recently introduced, advanced natural-orifice approach for myotomy. It is preferred for Type III Achalasia (spastic type).</li><li>• Per Oral Endoscopic Myotomy</li><li>• (POEM)</li><li>• Esophagectomy is considered in any symptomatic patient with the following: tortuous esophagus (megaoesophagus)/sigmoid esophagus.</li><li>• Ref : Bailey and Love 27 th Ed pages 1095-1099</li><li>• Ref</li><li>• : Bailey and Love 27 th Ed pages 1095-1099</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient presented with dysphagia to both solid and liquids. Manometry revealed IRP &gt; 15 and &gt;20% premature spastic contractions, but absent peristalsis. What is the diagnosis?", "options": [{"label": "A", "text": "Achalasia type 1", "correct": false}, {"label": "B", "text": "Achalasia type 2", "correct": false}, {"label": "C", "text": "Achalasia type 3", "correct": true}, {"label": "D", "text": "Jackhammer esophagus", "correct": false}], "correct_answer": "C. Achalasia type 3", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Achalasia type 3</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient presented with retrosternal chest pain radiating to the jaw and dysphagia. Barium swallow shows the following: What is your likely diagnosis?", "options": [{"label": "A", "text": "Achalasia cardia", "correct": false}, {"label": "B", "text": "Nutcracker esophagus", "correct": false}, {"label": "C", "text": "Diffuse esophageal spasm", "correct": true}, {"label": "D", "text": "Schatzski ring", "correct": false}], "correct_answer": "C. Diffuse esophageal spasm", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/27/screenshot-2023-04-26-123631_PP3ov5s.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Diffuse esophageal spasm</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Achalasia : Barium findings : Barium swallow in achalasia often shows a classic \"bird's beak\" appearance in the distal esophagus , representing a narrowing at the lower esophageal sphincter (LES), along with dilatation of the proximal esophagus.</li><li>• Option A. Achalasia</li><li>• Barium findings</li><li>• \"bird's beak\" appearance in the distal esophagus</li><li>• Manometry findings : In achalasia, manometry typically reveals: Elevated lower esophageal sphincter (LES) pressure or integrated relaxation pressure (IRP), absence of peristalsis or peristaltic contractions in the esophagus, incomplete relaxation of the LES during swallowing.</li><li>• Manometry findings</li><li>• Elevated lower esophageal sphincter</li><li>• pressure or integrated relaxation pressure</li><li>• Option B. Hypercontractile (jackhammer) oesophagus is characterised by high-amplitude contractions and should be differentiated from contractility disorder secondary to outflow obstruction . These abnormal contractions are more common in the distal two-thirds of the oesophageal body. Patients may present with dysphagia or pain. Barium may be normal.</li><li>• Option B. Hypercontractile (jackhammer) oesophagus</li><li>• high-amplitude contractions and should be differentiated from contractility disorder secondary to outflow obstruction</li><li>• Manometry typically reveals : Elevated distal esophageal contractile amplitudes , Normal or slightly elevated lower esophageal sphincter (LES) pressure, with exaggerated contractions in some segments of the esophagus.</li><li>• Manometry typically reveals</li><li>• Elevated distal esophageal contractile amplitudes</li><li>• Normal</li><li>• slightly elevated lower esophageal sphincter</li><li>• Option D. Schatzski ring: Barium findings: Barium swallow may show a narrowing or constriction in the distal esophagus , often at the level of the squamocolumnar junction, creating a \"waist\" appearance.</li><li>• Option D. Schatzski ring:</li><li>• narrowing or constriction in the distal esophagus</li><li>• Manometry findings : Manometry is not typically required for diagnosing Schatzki rings , as they are primarily diagnosed through barium swallow and endoscopy.</li><li>• Manometry findings</li><li>• not typically required for diagnosing Schatzki rings</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Hypermotility disorders like nutcracker esophagus (MC type), diffuse esophageal spasm present with dysphagia and are diagnosed on manometry .</li><li>• Hypermotility disorders</li><li>• nutcracker esophagus</li><li>• diffuse esophageal spasm</li><li>• dysphagia and are diagnosed on manometry</li><li>• There is no well-proven treatment strategy for hypercontractile motility disorders . Patients should avoid any identifiable triggering factors (E.g., dietary or GERD related).</li><li>• no well-proven treatment strategy for hypercontractile motility disorders</li><li>• Similar to achalasia, medical therapy such as calcium channel blockers, nitrates, 5′-phosphodiesterase inhibitors and pain modulators have been used with limited efficacy. Botulinum toxin injection in the oesophageal body may be useful. Long-segment surgical myotomy has been attempted with good results. POEM with extended myotomy is also advocated as a minimally invasive approach to treat these disorders.</li><li>• Ref : Bailey and love 28 th edition pg 1125</li><li>• Ref</li><li>• : Bailey and love 28 th edition pg 1125</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A baby was born to a mother who had polyhydramnios. The mother complains that the neonate is unable to feed properly. There is regurgitation of feeds and frothing of saliva. There are also signs of cyanosis. What is the incorrect statement with respect to the above condition?", "options": [{"label": "A", "text": "Type A is the most common type", "correct": true}, {"label": "B", "text": "This condition is often associated with VACTERL", "correct": false}, {"label": "C", "text": "Inability to pass a nasogastric tube aid in the diagnosis", "correct": false}, {"label": "D", "text": "There can be esophageal atresia without fistula formation too", "correct": false}], "correct_answer": "A. Type A is the most common type", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/05/picture2_hwSRPO0.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/05/picture3_ovKwVHG.jpg"], "explanation": "<p><strong>Ans. A) Type A is the most common type</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option B : On examination, association with VACTERL is often seen. (Vertebral, Anorectal, Cardiac, TEF, Renal and Limb anomalies)</li><li>• Option B</li><li>• VACTERL</li><li>• Option C : X ray confirms the presence of TEF when coiling of NGT is seen .</li><li>• Option C</li><li>• presence of TEF when coiling of NGT is seen</li><li>• Option D : In type A , there is only atresia without fistula.</li><li>• Option D</li><li>• type A</li><li>• only atresia without fistula.</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• The presentation is seen at birth . The treatment is always going to be early reconstruction . Type A and B have long gap between atretic segments of esophagus and require esophageal conduits for reconstruction.</li><li>• presentation is seen at birth</li><li>• treatment is always going to be early reconstruction</li><li>• Ref : Bailey 28 th Ed. Pg 265</li><li>• Ref</li><li>• : Bailey 28 th Ed. Pg 265</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is a severity symptom score of Achalasia?", "options": [{"label": "A", "text": "Chicago score", "correct": false}, {"label": "B", "text": "Allgrove score", "correct": false}, {"label": "C", "text": "Eckardt score", "correct": true}, {"label": "D", "text": "DeMeester score", "correct": false}], "correct_answer": "C. Eckardt score", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/05/screenshot-2023-12-05-154605.jpg"], "explanation": "<p><strong>Ans. C) Eckardt score</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A. Chicago Score : The Chicago Classification is a system used to categorize esophageal motility disorders based on high-resolution manometry findings . It is a diagnostic tool based on pressure measurements within the esophagus.</li><li>• Option A. Chicago Score</li><li>• system used to categorize esophageal motility disorders</li><li>• high-resolution manometry findings</li><li>• Option B. Allgrove Score : Allgrove syndrome, also known as triple-A syndrome , includes alacrima, achalasia, and adrenal abnormalities.</li><li>• Option B. Allgrove Score</li><li>• triple-A syndrome</li><li>• alacrima, achalasia, and adrenal abnormalities.</li><li>• Option D. DeMeester Score : The DeMeester score is a composite score used to quantify acid reflux . It is calculated using data from a 24-hour pH monitoring study and is not specific to Achalasia but rather to gastroesophageal reflux disease (GERD).</li><li>• Option D. DeMeester Score</li><li>• composite score used to quantify acid reflux</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Eckardt score is specifically used to quantify the severity of symptoms in patients with Achalasia , with the score based on the assessment of dysphagia, regurgitation, chest pain, and weight loss.</li><li>➤ Eckardt score</li><li>➤ quantify the severity of symptoms</li><li>➤ patients with Achalasia</li><li>➤ Eckardt score</li><li>➤ Eckardt score</li><li>➤ Ref : Bailey 28 th Ed. Pg 1122, table 66.1</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 1122, table 66.1</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "What is the optimal length of myotomy in Heller’s cardiomyotomy?", "options": [{"label": "A", "text": "Lower esophagus 2 cm, Cardia 2 cm", "correct": false}, {"label": "B", "text": "Lower esophagus 6 cm, Cardia 2 cm", "correct": true}, {"label": "C", "text": "Lower esophagus 2 cm, cardia 6 cm", "correct": false}, {"label": "D", "text": "Lower esophagus 6 cm, cardia 6 cm", "correct": false}], "correct_answer": "B. Lower esophagus 6 cm, Cardia 2 cm", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Lower esophagus 6 cm, cardia 2 cm</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Heller’s myotomy : Anterior myotomy is performed for at least 6 cm proximally at the oesophageal side and 2–3 cm distally into the gastric cardia . Transabdominal or transthoracic approaches have been advocated. Currently, the standard procedure is a laparoscopic approach .</li><li>• Heller’s myotomy</li><li>• Anterior myotomy</li><li>• least 6 cm proximally at the oesophageal side and 2–3 cm distally into the gastric cardia</li><li>• the standard procedure is a laparoscopic approach</li><li>• The major complication is GORD , which can occur in up to 40% of patients . The addition of a partial fundoplication (anterior Dor or posterior Toupet) has been shown to be effective in reducing the incidence of GORD.</li><li>• major complication is GORD</li><li>• occur in up to 40% of patients</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• The optimal length of myotomy in Heller’s cardiomyotomy is 6 cm towards Lower esophagus 6 cm and 2 cm towards gastric cardia.</li><li>• Lower esophagus 6 cm and 2 cm towards gastric cardia.</li><li>• Ref : Bailey and Lover 28 th Ed. Pg 1124</li><li>• Ref</li><li>• : Bailey and Lover 28 th Ed. Pg 1124</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is not associated with congenital Tracheo-esophageal fistula?", "options": [{"label": "A", "text": "Meningomyelocele", "correct": true}, {"label": "B", "text": "Syndactyly", "correct": false}, {"label": "C", "text": "Renal agenesis", "correct": false}, {"label": "D", "text": "VSD", "correct": false}], "correct_answer": "A. Meningomyelocele", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Meningomyelocele</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 60-year-old female with dementia, presented to the OPD with complaints of a fish bone stuck in her esophagus while eating. She is facing difficulty in swallowing. Flexible endoscopy was done to remove the bone, and the surgeon noticed that the foreign body was stuck in the esophagus about 15 cm from the incisors. What is the probable site of the foreign body ?", "options": [{"label": "A", "text": "Cricopharyngeal Junction", "correct": true}, {"label": "B", "text": "Left mainstem bronchus", "correct": false}, {"label": "C", "text": "Diaphragm", "correct": false}, {"label": "D", "text": "Gastroesophageal junction", "correct": false}], "correct_answer": "A. Cricopharyngeal Junction", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/05/screenshot-2023-12-05-160453.jpg"], "explanation": "<p><strong>Ans. A) Cricopharyngeal Junction</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The cricopharyngeal junction is the first physiological narrowing of esophagus, where foreign bodies can get impacted</li><li>➤ The cricopharyngeal junction is the first physiological narrowing of esophagus, where foreign bodies can get impacted</li><li>➤ Ref : Bailey and Love 28 th ed, Pg 1132</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th ed, Pg 1132</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 40-year-old male presents with complaints of vomiting and chest pain. Examination reveals subcutaneous emphysema on chest. The physician suspects Boerhaave’s syndrome. What is the most likely site of injury leading to these findings?", "options": [{"label": "A", "text": "Upper third of esophagus", "correct": false}, {"label": "B", "text": "Middle third of esophagus", "correct": false}, {"label": "C", "text": "Lower third of esophagus", "correct": true}, {"label": "D", "text": "Gastro-esophageal junction", "correct": false}], "correct_answer": "C. Lower third of esophagus", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Lower third of esophagus.</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "An elderly male presents with halitosis and regurgitation of food at night. On examination, there is a gurgling sound on neck palpation. Barium study is as below. What is the diagnosis?", "options": [{"label": "A", "text": "Pharyngeal pouch", "correct": true}, {"label": "B", "text": "Plummer Vinson syndrome", "correct": false}, {"label": "C", "text": "Dysphagia lusoria", "correct": false}, {"label": "D", "text": "Laryngocele", "correct": false}], "correct_answer": "A. Pharyngeal pouch", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/01/untitled-168.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/08/untitled-320.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/08/untitled-321.jpg"], "explanation": "<p><strong>Ans. A) Pharyngeal pouch</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option B . Plummer Vinson syndrome is characterized by dysphagia , iron deficiency anemia , and esophageal webs or strictures , but it does not typically present with regurgitation or a gurgling sound on neck palpation.</li><li>• Option B</li><li>• Plummer Vinson syndrome</li><li>• dysphagia</li><li>• iron deficiency anemia</li><li>• esophageal webs or strictures</li><li>• Option C . Dysphagia lusoria is a rare condition where there is compression of the esophagus by an aberrant right subclavian artery , leading to dysphagia, but it does not typically present with regurgitation or halitosis.</li><li>• Option C</li><li>• Dysphagia lusoria</li><li>• rare condition where there is compression of the esophagus by an aberrant right subclavian artery</li><li>• Option D . Laryngocele is a condition involving a cystic dilatation of the laryngeal saccule , and it typically presents with hoarseness or airway symptoms, not regurgitation or halitosis.</li><li>• Option D</li><li>• Laryngocele</li><li>• cystic dilatation of the laryngeal saccule</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Clinical features of Zenker’s:</li><li>• Clinical features of Zenker’s:</li><li>• Pharyngeal dysphagia. As the pouch enlarges, it tends to fill with food on eating, and the fundus descends into the mediastinum. Regurgitation of trapped food can occur and lead to aspiration. Halitosis.</li><li>• Pharyngeal dysphagia.</li><li>• As the pouch enlarges, it tends to fill with food on eating, and the fundus descends into the mediastinum.</li><li>• Regurgitation of trapped food can occur and lead to aspiration.</li><li>• Halitosis.</li><li>• Diagnosis : Ba swallow /CT neck with oral contrast</li><li>• Diagnosis</li><li>• Ba swallow</li><li>• Treatment:</li><li>• Treatment:</li><li>• Open left cervical incision (most diverticula point towards the left side) with diverticulectomy and cricopharyngeal myotomy . Endoscopic diverticulopexy (Dohlman’s procedure) or stapled diverticulopexy are alternatives.</li><li>• Open left cervical incision</li><li>• diverticulectomy and cricopharyngeal myotomy</li><li>• Ref : Bailey and love 28 th ed: 1126-1127</li><li>• Ref</li><li>• : Bailey and love 28 th ed: 1126-1127</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the procedure shown in the image:", "options": [{"label": "A", "text": "POEMs procedure", "correct": false}, {"label": "B", "text": "Heller’s cardiomyotomy", "correct": false}, {"label": "C", "text": "Endoscopic stapled diverticulopexy", "correct": true}, {"label": "D", "text": "Stricture dilatation", "correct": false}], "correct_answer": "C. Endoscopic stapled diverticulopexy", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/01/esophagus-part-1-5.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Endoscopic stapled diverticulopexy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A. POEMs procedure (Peroral Endoscopic Myotomy) : The POEMs procedure is a minimally invasive endoscopic surgical technique used to treat achalasia , not Zenker's diverticulum. It involves making a tunnel through the inner lining of the esophagus and performing a myotomy (cutting of the muscle) to relax the lower esophageal sphincter, improving the passage of food into the stomach.</li><li>• Option</li><li>• A. POEMs procedure (Peroral Endoscopic Myotomy)</li><li>• POEMs procedure</li><li>• minimally invasive endoscopic surgical technique used to treat achalasia</li><li>• Option B. Heller’s cardiomyotomy (Heller myotomy) : Heller's cardiomyotomy is a surgical procedure used to treat achalasia , not Zenker's diverticulum. It involves cutting the muscle at the lower end of the esophagus (lower esophageal sphincter) to relieve the obstruction that occurs in achalasia.</li><li>• Option</li><li>• B. Heller’s cardiomyotomy (Heller myotomy)</li><li>• surgical procedure used to treat achalasia</li><li>• Option D. Stricture dilatation : Stricture dilation involves the use of a dilating balloon to stretch and widen a narrowed or constricted part of the esophagus. This procedure is often used to treat strictures or narrowing caused by conditions such as esophageal cancer , peptic strictures, or eosinophilic esophagitis.</li><li>• Option</li><li>• D. Stricture dilatation</li><li>• use of a dilating balloon to stretch and widen a narrowed or constricted part of the esophagus.</li><li>• treat strictures or narrowing caused by conditions such as esophageal cancer</li><li>• Educational objective :</li><li>• Educational objective</li><li>• :</li><li>• Endoscopic stapled diverticulopexy is the procedure depicted in the image for resolving Zenker’s diverticulum.</li><li>• Endoscopic stapled diverticulopexy</li><li>• Zenker’s diverticulum.</li><li>• Ref : Bailey 28 th Ed. Pg 1127</li><li>• Ref</li><li>• : Bailey 28 th Ed. Pg 1127</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old patient with a history of achalasia, had undergone a POEM procedure, following which he developed left sided pleural effusion. A crunching sound was heard on auscultation of the heart. What is your investigation of choice in such a case?", "options": [{"label": "A", "text": "CT with non-ionic contrast swallow study", "correct": true}, {"label": "B", "text": "Upper GI endoscopy", "correct": false}, {"label": "C", "text": "Barium swallow", "correct": false}, {"label": "D", "text": "Manometry", "correct": false}], "correct_answer": "A. CT with non-ionic contrast swallow study", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) CT with non-ionic contrast swallow study</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option B. While Upper GI Endoscopy and Option C. Barium Swallow are useful for evaluating esophageal conditions , they are not be the most appropriate initial investigations for assessing a pleural effusion and potential complications after a POEM procedure.</li><li>• Option B. While Upper GI Endoscopy</li><li>• Option C. Barium Swallow</li><li>• useful for evaluating esophageal conditions</li><li>• Option D. Manometry is a diagnostic test for assessing esophageal motility disorders , but it may not provide the information needed to evaluate the pleural effusion and related symptoms in this case.</li><li>• Option D. Manometry</li><li>• diagnostic test for assessing esophageal motility disorders</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Gastric juice as well as ingested food is forcefully ejected into the mediastinum following perforation. A left pleural effusion rapidly accumulates . Hamman’s sign refers to a crunching sound on auscultation of the heart owing to surgical emphysema .</li><li>• Gastric juice</li><li>• ingested food is forcefully ejected into the mediastinum following perforation.</li><li>• left pleural effusion</li><li>• accumulates</li><li>• Hamman’s sign</li><li>• crunching sound on auscultation of the heart owing to surgical emphysema</li><li>• Contrast swallow study using Gastrografin or a non-ionic contrast usually reveals the site of perforation .</li><li>• Contrast swallow study</li><li>• Gastrografin or a non-ionic contrast</li><li>• site of perforation</li><li>• Ref : Bailey 28 th ed. Pg: 1127-1128</li><li>• Ref</li><li>• : Bailey 28 th ed. Pg: 1127-1128</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the incorrect statement with respect to Zenker’s diverticulum?", "options": [{"label": "A", "text": "Zenker’s diverticulum is a true pulsion diverticulum", "correct": true}, {"label": "B", "text": "Protrudes posteriorly above the cricopharyngeal sphincter through the dehiscence of Killian", "correct": false}, {"label": "C", "text": "The muscle involved is the inferior constrictor", "correct": false}, {"label": "D", "text": "Regurgitation, halitosis and aspiration are common symptoms", "correct": false}], "correct_answer": "A. Zenker’s diverticulum is a true pulsion diverticulum", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Zenker’s diverticulum is a true pulsion diverticulum</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the investigation and its primary role.", "options": [{"label": "A", "text": "24-hour pH study in GERD", "correct": false}, {"label": "B", "text": "Esophageal manometry in motility disorders", "correct": true}, {"label": "C", "text": "24-hour pH study in motility disorders", "correct": false}, {"label": "D", "text": "Esophageal manometry in hiatus hernia", "correct": false}], "correct_answer": "B. Esophageal manometry in motility disorders", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/image_2TsMdoz.png"], "explanation_images": [], "explanation": "<p><strong>Ans. B)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation :</li><li>• Option A. 24 Hour pH study involves measuring acid levels in lower esophagus, which is not depicted in the image.</li><li>• Option A. 24 Hour pH study involves measuring acid levels in lower esophagus, which is not depicted in the image.</li><li>• Option C. 24 Hour pH study is not performed for motility disorders, but for GERD.</li><li>• Option C. 24 Hour pH study is not performed for motility disorders, but for GERD.</li><li>• Option D. Though esophageal manometry may provide clue to low pressure in lower esophagus, which is associated with hiatus hernia, it is not commonly performed for it. Hiatus hernia is better diagnosed on oral contrast imaging like CT or Barium swallow.</li><li>• Option D. Though esophageal manometry may provide clue to low pressure in lower esophagus, which is associated with hiatus hernia, it is not commonly performed for it. Hiatus hernia is better diagnosed on oral contrast imaging like CT or Barium swallow.</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Motility disorders of esophagus are best diagnosed on esophageal manometry.</li><li>• Motility disorders of esophagus are best diagnosed on esophageal manometry.</li><li>• Ref : Bailey 28th Ed. Pg 1121-22</li><li>• Ref : Bailey 28th Ed. Pg 1121-22</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In which of the below etiology of esophageal perforation is operative management preferred over conservative?", "options": [{"label": "A", "text": "Mediastinum involvement", "correct": false}, {"label": "B", "text": "Cervical perforation", "correct": false}, {"label": "C", "text": "Boerhaave syndrome", "correct": true}, {"label": "D", "text": "Perforation caused by fibre optic endoscopy", "correct": false}], "correct_answer": "C. Boerhaave syndrome", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/05/screenshot-2023-12-05-163230.jpg"], "explanation": "<p><strong>Ans. C) Boerhaave syndrome</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A. Mediastinum involvement : Mediastinal involvement or extension of the perforation may indicate a more severe case , but whether operative or conservative management is preferred depends on the specific clinical circumstances and the extent of the injury. Surgical intervention may be necessary in some cases with mediastinal involvement.</li><li>• Option</li><li>• A. Mediastinum involvement</li><li>• extension of the perforation may indicate a more severe case</li><li>• Option B. Cervical perforation : Cervical esophageal perforation may sometimes be managed conservatively with non-operative measures , such as antibiotics and nutritional support , depending on the size and extent of the perforation. However, surgical intervention may be required in certain cases.</li><li>• Option</li><li>• B. Cervical perforation</li><li>• managed conservatively with non-operative measures</li><li>• antibiotics and nutritional support</li><li>• Option D. Perforation caused by fiber optic endoscopy : Perforations caused by diagnostic or therapeutic endoscopy, including fiber optic endoscopy, are typically managed based on the size and location of the perforation . Small, contained perforations may be managed conservatively with close monitoring, while larger or complicated perforations may require surgical repair</li><li>• Option</li><li>• D. Perforation caused by fiber optic endoscopy</li><li>• including fiber optic endoscopy,</li><li>• managed based on the size and location of the perforation</li><li>• Educational objective :</li><li>• Educational objective</li><li>• :</li><li>• Perforation of the oesophagus usually leads to mediastinitis. The aim of treatment is to limit mediastinal contamination and prevent or deal with infection. The decision between operative and non-operative management rests on four factors . These are:</li><li>• Perforation of the oesophagus usually leads to mediastinitis. The aim of treatment is to limit mediastinal contamination and prevent or deal with infection.</li><li>• Perforation of the oesophagus</li><li>• mediastinitis.</li><li>• The decision between operative and non-operative management rests on four factors . These are:</li><li>• The decision between operative and non-operative management rests on four factors</li><li>• The site of the perforation (cervical versus thoraco-abdominal oesophagus). The event causing the perforation (spontaneous versus instrumental). Underlying pathology (benign or malignant). The status of the oesophagus before the perforation (fasted and empty versus obstructed with stagnant residue).</li><li>• The site of the perforation (cervical versus thoraco-abdominal oesophagus).</li><li>• The event causing the perforation (spontaneous versus instrumental).</li><li>• Underlying pathology (benign or malignant).</li><li>• The status of the oesophagus before the perforation (fasted and empty versus obstructed with stagnant residue).</li><li>• Surgical management is required whenever patients are unstable with sepsis or shock ; have evidence of a heavily contaminated mediastinum, pleural space or peritoneum; have widespread intrapleural or intraperitoneal extravasation of contrast material.</li><li>• Surgical management is required whenever patients are unstable with sepsis or shock ; have evidence of a heavily contaminated mediastinum, pleural space or peritoneum; have widespread intrapleural or intraperitoneal extravasation of contrast material.</li><li>• Surgical management is required whenever patients are unstable with sepsis or shock</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is an unlikely complication of Heller’s cardiomyotomy?", "options": [{"label": "A", "text": "Esophageal perforation", "correct": false}, {"label": "B", "text": "Post-operative acid reflux", "correct": false}, {"label": "C", "text": "Vagus nerve injury", "correct": false}, {"label": "D", "text": "Gas bloat syndrome", "correct": true}], "correct_answer": "D. Gas bloat syndrome", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Explanation:</strong></p><ul><li>• Heller’s myotomy involves cutting the muscle of the lower oesophagus and gastric cardia.</li><li>• Heller’s myotomy involves cutting the muscle of the lower oesophagus and gastric cardia.</li><li>• Option D: Gas bloat syndrome is seen after Nissen’s fundoplication. The patient complains of gaseous distension of the abdomen and failure to belch or vomit, together with an increase in flatulence.</li><li>• Option D: Gas bloat syndrome is seen after Nissen’s fundoplication. The patient complains of gaseous distension of the abdomen and failure to belch or vomit, together with an increase in flatulence.</li><li>• Option B: The major complication is GERD, which can occur in up to 40% of patients. The addition of a partial fundoplication (anterior Dor or posterior Toupet) has been shown to be effective in reducing the incidence of GERD.</li><li>• Option B: The major complication is GERD, which can occur in up to 40% of patients. The addition of a partial fundoplication (anterior Dor or posterior Toupet) has been shown to be effective in reducing the incidence of GERD.</li><li>• Option A and C: Esophageal perforation due to accidental tearing of mucosa and injury to the anterior Vagus nerve during myotomy are possible.</li><li>• Option A and C: Esophageal perforation due to accidental tearing of mucosa and injury to the anterior Vagus nerve during myotomy are possible.</li><li>• Educational objective: Heller’s myotomy, the procedure of choice for achalasia (type 1 and 2), is associated with complications like GERD, which may be avoided by adding anti-reflux fundoplications.</li><li>• Educational objective: Heller’s myotomy, the procedure of choice for achalasia (type 1 and 2), is associated with complications like GERD, which may be avoided by adding anti-reflux fundoplications.</li><li>• Ref: Bailey 28 th Ed. Pg 1116, 1122-23.</li><li>• Ref: Bailey 28 th Ed. Pg 1116, 1122-23.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is incorrect about esophageal anatomy?", "options": [{"label": "A", "text": "Lined mainly by squamous epithelium", "correct": false}, {"label": "B", "text": "Z line represent the gastro-esophageal junction on endoscopy", "correct": false}, {"label": "C", "text": "The lower esophageal sphincter (LES) has both intra-abdominal and thoracic components", "correct": false}, {"label": "D", "text": "The right bronchus causes indentation at 25 cm from incisors", "correct": true}], "correct_answer": "D. The right bronchus causes indentation at 25 cm from incisors", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A . While the majority of the esophagus is lined by stratified squamous epithelium , the lower part of the esophagus , particularly the lower esophageal sphincter (LES) and the area immediately above it , is lined by a different type of epithelium called gastric or columnar epithelium . This transition from squamous to columnar epithelium is known as the gastroesophageal junction (GEJ) and is significant in the context of conditions like gastroesophageal reflux disease (GERD).</li><li>• Option A</li><li>• majority of the esophagus is lined by stratified squamous epithelium</li><li>• lower part of the esophagus</li><li>• lower esophageal sphincter</li><li>• area immediately above it</li><li>• lined by a different type of epithelium called gastric or columnar epithelium</li><li>• Option B . The Z-line represents the gastroesophageal junction on endoscopy , where the squamous epithelium of the esophagus transitions to the columnar epithelium of the stomach .</li><li>• Option B</li><li>• Z-line represents the gastroesophageal junction on endoscopy</li><li>• squamous epithelium of the esophagus transitions to the columnar epithelium of the stomach</li><li>• Option C . The LES (Lower Esophageal Sphincter) has both intra-abdominal and thoracic components. The intra-abdominal portion of the LES plays a crucial role in preventing gastroesophageal reflux .</li><li>• Option</li><li>• C</li><li>• LES</li><li>• intra-abdominal portion of the LES plays a crucial role in preventing gastroesophageal reflux</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• The left bronchus and left atrium/aorta cause indentation on esophagus and not the right bronchus.</li><li>• left bronchus and left atrium/aorta cause indentation on esophagus</li><li>• Ref : Bailey and Love 28 th Ed. Pg 1106-07.</li><li>• Ref</li><li>• Bailey and Love 28 th Ed. Pg 1106-07.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is the preferred treatment for type 3 Achalasia?", "options": [{"label": "A", "text": "Endoscopic dilation", "correct": false}, {"label": "B", "text": "Heller’s myotomy", "correct": false}, {"label": "C", "text": "POEM", "correct": true}, {"label": "D", "text": "Esophagectomy", "correct": false}], "correct_answer": "C. POEM", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Heller's myotomy (Option B) is also a treatment option for achalasia , but it is generally more commonly used for type 1 and type 2 achalasia. Endoscopic dilation (Option A) may be considered in some cases but is often less effective for type 3 achalasia compared to POEM.</li><li>• Heller's myotomy</li><li>• treatment option for achalasia</li><li>• Endoscopic dilation</li><li>• considered in some cases</li><li>• less effective for type 3 achalasia</li><li>• Educational objective :</li><li>• Educational objective</li><li>• :</li><li>• Treatment of choice for :</li><li>• Treatment of choice for</li><li>• Type 1 and Type 2 Achalasia: Heller’s myotomy Type 3 Achalasia/Jackhammer esophagus/Distal esophageal spasm: POEM with long myotomy Megaoesophagus/End stage achalasia: Esophagectomy</li><li>• Type 1 and Type 2 Achalasia: Heller’s myotomy</li><li>• Type 3 Achalasia/Jackhammer esophagus/Distal esophageal spasm: POEM with long myotomy</li><li>• Megaoesophagus/End stage achalasia: Esophagectomy</li><li>• Ref : Bailey and Love 28 th Ed. Pg 1124</li><li>• Ref</li><li>• : Bailey and Love 28 th Ed. Pg 1124</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old male patient presented to the physician with complaints of heartburn and a sour taste in the mouth for the past 1 year. The physician prescribed him proton pump inhibitors, but the symptoms did not improve. What is the immediate next step in the management of this patient?", "options": [{"label": "A", "text": "Endoscopy", "correct": true}, {"label": "B", "text": "24-hour pH recording", "correct": false}, {"label": "C", "text": "Esophageal manometry", "correct": false}, {"label": "D", "text": "Fundoplication", "correct": false}], "correct_answer": "A. Endoscopy", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Endoscopy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. 24-hour pH recording - This is a diagnostic test used to confirm GERD by measuring the frequency and duration of acid reflux episodes . It's typically considered when the diagnosis of GERD is uncertain or to evaluate the effectiveness of acid-suppression therapy or prior to surgery for GERD.</li><li>• Option B. 24-hour pH recording</li><li>• diagnostic test used to confirm GERD</li><li>• measuring the frequency</li><li>• duration of acid reflux episodes</li><li>• Option C. Esophageal manometry - This test measures the function of the lower esophageal sphincter and the esophageal muscles . It's generally used in the workup of patients with suspected motility disorders.</li><li>• Option C. Esophageal manometry</li><li>• test measures the function of the lower esophageal sphincter and the esophageal muscles</li><li>• Option D. Fundoplication - This is a surgical procedure used to treat GERD . It is considered when medical therapy fails and the diagnosis of GERD is confirmed , but it is not a diagnostic step and is not appropriate as an immediate next step without further evaluation.</li><li>• Option D. Fundoplication</li><li>• surgical procedure used to treat GERD</li><li>• medical therapy fails and the diagnosis of GERD is confirmed</li><li>• Given these options, the most appropriate immediate next step in the management of this patient is A. Endoscopy.</li><li>• Educational objective :</li><li>• Educational objective</li><li>• :</li><li>• In patients with reflux symptoms not responding to PPI, the diagnosis is confirmed by first performing an endoscopy. 24-hour pH recording of GERD- gold standard investigation:</li><li>• In patients with reflux symptoms not responding to PPI, the diagnosis is confirmed by first performing an endoscopy.</li><li>• 24-hour pH recording of GERD- gold standard investigation:</li><li>• In this procedure, a pH probe is placed 5 cm above the upper end of the lower esophageal sphincter for 24 hours.</li><li>• 5 cm above the upper end</li><li>• of the lower esophageal sphincter</li><li>• Reflux is defined as a drop of pH below 4 for more than 4% time in a 24-hour period or DeMeester scoring of 14.7 or higher.</li><li>• Reflux is defined as a drop of pH below 4 for more than 4% time in a 24-hour period or DeMeester scoring of 14.7 or higher.</li><li>• drop of pH below 4 for more than 4% time in a 24-hour period</li><li>• Ref : Bailey and Love 28 th edition Pg 1114</li><li>• Ref :</li><li>• Bailey and Love 28 th edition Pg 1114</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 35-year-old female patient came to the physician with complaints of heartburn and regurgitation of food. The symptoms have been present for 3 years but have worsened for the past 3 months. She took over the counter medications, but the symptoms did not subside. Upper GI endoscopy shows the following presentation: What is your probable diagnosis?", "options": [{"label": "A", "text": "Barrett’s esophagus", "correct": true}, {"label": "B", "text": "Schatzki ring", "correct": false}, {"label": "C", "text": "Eosinophilic esophagitis", "correct": false}, {"label": "D", "text": "Pseudo-achalasia", "correct": false}], "correct_answer": "A. Barrett’s esophagus", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/01/untitled-172.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. A) Barrett’s esophagus</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. Schatzki Ring – A Schatzki ring is a narrowing of the lower esophagus that can cause difficulty swallowing (dysphagia). It typically appears as a thin ring on endoscopy and wouldn't show the patchy red mucosa that is indicative of Barrett’s esophagus. The symptoms of heartburn and regurgitation are less specific to a Schatzki ring unless there is accompanying esophagitis.</li><li>• Option B. Schatzki Ring</li><li>• Schatzki ring</li><li>• narrowing of the lower esophagus</li><li>• cause difficulty swallowing</li><li>• thin ring on endoscopy</li><li>• wouldn't show the patchy red mucosa</li><li>• Barrett’s esophagus.</li><li>• Option C. Eosinophilic Esophagitis – This is an allergic/immune condition that results in a buildup of eosinophils in the esophagus , leading to esophageal dysfunction . On endoscopy, it can show multiple rings, white specks of eosinophilic infiltrates, and longitudinal furrows, none of which are visible in the provided image.</li><li>• Option C. Eosinophilic Esophagitis</li><li>• allergic/immune condition</li><li>• buildup of eosinophils in the esophagus</li><li>• esophageal dysfunction</li><li>• Option D. Pseudo-Achalasia – This refers to symptoms of achalasia due to carcinoma of esophagus . It would not cause the visible changes seen in Barrett’s esophagus on endoscopy.</li><li>• Option D. Pseudo-Achalasia</li><li>• symptoms of achalasia due to carcinoma of esophagus</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Barrett’s esophagus is the columnar metaplasia of lower esophagus.</li><li>• Barrett’s esophagus</li><li>• columnar metaplasia of lower esophagus.</li><li>• Etiology/risk factors:</li><li>• Etiology/risk factors:</li><li>• Chronic (&gt;5 years) GERD symptoms, Advanced age (&gt;50 years), Smoking, central obesity Male gender.</li><li>• Chronic (&gt;5 years) GERD symptoms,</li><li>• Advanced age (&gt;50 years),</li><li>• Smoking, central obesity</li><li>• Male gender.</li><li>• Clinical features:</li><li>• Clinical features:</li><li>• The vast majority of patients with Barrett’s esophagus in the community are asymptomatic</li><li>• The vast majority of patients with Barrett’s esophagus in the community are asymptomatic</li><li>• Diagnosis:</li><li>• Diagnosis:</li><li>• Through upper GI endoscopy with biopsy or chromoendoscopy. Biopsy shows the presence of columnar epithelium with mucus-secreting goblet cells (intestinal metaplasia). This is an important risk factor for adenocarcinoma of the esophagus .</li><li>• Through upper GI endoscopy</li><li>• biopsy or chromoendoscopy.</li><li>• This is an important risk factor for adenocarcinoma of the esophagus</li><li>• Treatment:</li><li>• Treatment:</li><li>• When Barrett’s esophagus is discovered, the treatment is that of the underlying GERD. Radio frequency ablation of mucosa High grade dysplastic cases: esophagectomy</li><li>• When Barrett’s esophagus is discovered, the treatment is that of the underlying GERD.</li><li>• Radio frequency ablation of mucosa</li><li>• High grade dysplastic cases: esophagectomy</li><li>• Ref : Bailey and Love 28 th ed: page 1120</li><li>• Ref :</li><li>• Bailey and Love 28 th ed: page 1120</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the odd one out with respect to risk factors of squamous cell carcinoma of esophagus?", "options": [{"label": "A", "text": "Tobacco", "correct": false}, {"label": "B", "text": "Alcohol", "correct": false}, {"label": "C", "text": "Barrett’s esophagus", "correct": true}, {"label": "D", "text": "HPV", "correct": false}], "correct_answer": "C. Barrett’s esophagus", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Barrett’s esophagus</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Barrett’s esophagus is the columnar metaplasia of lower esophagus . It is a risk factor for adenocarcinoma .</li><li>• Barrett’s esophagus</li><li>• columnar metaplasia of lower esophagus</li><li>• risk factor for adenocarcinoma</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Most common type of esophageal carcinoma: Squamous cell carcinoma</li><li>• Squamous cell carcinoma</li><li>• Risk factors for SCC:</li><li>• Risk factors for SCC:</li><li>• Spirits: alcohol Spices Sepsis: HPV Smoking Plummer Vinson syndrome Achalasia</li><li>• Spirits: alcohol</li><li>• Spices</li><li>• Sepsis: HPV</li><li>• Smoking</li><li>• Plummer Vinson syndrome</li><li>• Achalasia</li><li>• Risk factors for adenocarcinoma:</li><li>• Risk factors for adenocarcinoma:</li><li>• Barrett's esophagus GERD Smoking Obesity</li><li>• Barrett's esophagus</li><li>• GERD</li><li>• Smoking</li><li>• Obesity</li><li>• Ref : Bailey and Love 28 th Ed pg 1136</li><li>• Ref :</li><li>• Bailey and Love 28 th Ed pg 1136</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the incorrect statement with respect to GERD?", "options": [{"label": "A", "text": "Sliding hiatus hernia predisposes to GERD", "correct": false}, {"label": "B", "text": "Heartburn and regurgitation are typical GERD symptoms", "correct": false}, {"label": "C", "text": "Regurgitation in GERD is well controlled by PPI’s", "correct": true}, {"label": "D", "text": "Extraesophageal symptoms may include chronic cough, laryngitis, asthma and dental erosions", "correct": false}], "correct_answer": "C. Regurgitation in GERD is well controlled by PPI’s", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Regurgitation in GERD is well controlled by PPI’s</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Hiatus hernia is associated with GERD ; it is formed when the weakened phreno-esophageal ligament and widened crural opening allow the proximal stomach to herniate through the diaphragmatic hiatus . Ageing, connective tissue disease and elevated intra-abdominal pressure (e.g., central obesity, pregnancy, tight garments, chronic straining) will further aggravate the hernia. An acid pocket is an area of unbuffered gastric acid that accumulates in the proximal stomach after meals and serves as a reservoir for acid reflux. Together with a hiatus hernia, it can exacerbate the severity and symptoms of GERD.</li><li>• Option A:</li><li>• Hiatus hernia</li><li>• GERD</li><li>• formed when the weakened phreno-esophageal ligament</li><li>• widened crural opening allow the proximal stomach to herniate through the diaphragmatic hiatus</li><li>• An acid pocket is an area of unbuffered gastric acid that accumulates in the proximal stomach after meals</li><li>• Option B: Classical triad of GERD includes:</li><li>• Option B: Classical triad of GERD includes:</li><li>• Heartburn Regurgitation Epigastric pain</li><li>• Heartburn</li><li>• Regurgitation</li><li>• Epigastric pain</li><li>• Symptoms are often provoked by food, particularly after a full meal with increased intragastric pressure or food that delays gastric emptying (e.g., oily, spicy food). The reflux can cause an unpleasant taste, often described as ‘acidic’ or ‘bitter’.</li><li>• The reflux can cause an unpleasant taste, often described as ‘acidic’ or ‘bitter’.</li><li>• Option D: Extraesophageal symptoms may include chronic cough, laryngitis, asthma and dental erosions (especially on the lingual and palatal tooth surfaces). Other conditions with proposed association with GERD include sinusitis, pulmonary fibrosis, pharyngitis and recurrent otitis media.</li><li>• Option D:</li><li>• Extraesophageal symptoms</li><li>• chronic cough, laryngitis, asthma and dental erosions</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Regurgitation in patients with GERD is a feature of advanced disease . While most patients’ symptoms are satisfactorily controlled with PPIs and other medications, surgery remains an important option.</li><li>• Regurgitation</li><li>• GERD is a feature of advanced disease</li><li>• The indications for surgery include:</li><li>• Incomplete symptom control with medical management, Intolerance of, or unwillingness to comply with, long-term medical therapy, Regurgitation despite medication (less well amenable to PPI) , Presence of a large hiatus hernia, Complications arising from GORD, and (vi) extra-esophageal symptoms.</li><li>• Incomplete symptom control with medical management,</li><li>• Intolerance of, or unwillingness to comply with, long-term medical therapy,</li><li>• Regurgitation despite medication (less well amenable to PPI) ,</li><li>• Regurgitation despite medication (less well amenable to PPI)</li><li>• Presence of a large hiatus hernia,</li><li>• Complications arising from GORD, and (vi) extra-esophageal symptoms.</li><li>• Ref : Bailey and Love, 28 th Ed. Pg 1111 to 1116</li><li>• Ref :</li><li>• Bailey and Love, 28 th Ed. Pg 1111 to 1116</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the anti-reflux procedure in the image?", "options": [{"label": "A", "text": "Floppy Nissen fundoplication", "correct": true}, {"label": "B", "text": "Toupet fundoplication", "correct": false}, {"label": "C", "text": "Dor Fundoplication", "correct": false}, {"label": "D", "text": "Allison’s cruroplasty", "correct": false}], "correct_answer": "A. Floppy Nissen fundoplication", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/01/surgery-12.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. A) Floppy Nissen fundoplication</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation :</li><li>• The shown image is of 360-degree fundal wrap also called as floppy Nissen fundoplication.</li><li>• 360-degree fundal wrap</li><li>• floppy Nissen fundoplication.</li><li>• Toupet: Posterior 270 ° wrap Dor: Anterior 180 ° wrap Allison’s: Only crura is repaired , no fundal wrap.</li><li>• Toupet: Posterior 270 ° wrap</li><li>• Toupet: Posterior 270 ° wrap</li><li>• Toupet:</li><li>• Posterior 270 ° wrap</li><li>• Dor: Anterior 180 ° wrap</li><li>• Dor: Anterior 180 ° wrap</li><li>• Dor:</li><li>• Anterior 180 ° wrap</li><li>• Allison’s: Only crura is repaired , no fundal wrap.</li><li>• Allison’s: Only crura is repaired , no fundal wrap.</li><li>• Allison’s:</li><li>• crura is repaired</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The mechanism of fundoplication is to create a ‘floppy’ 360 degree wrap around the Gastro-esophageal junction and to restore the angle of His. It has the effect of increasing lower esophageal sphincter (LES) basal pressure, lessening transient lower esophageal sphincter relaxation (TLOSR) and reducing the capacity of the gastric fundus, thereby enhancing gastric emptying. Complete fundoplication (Nissen) is associated with a higher incidence of short-term dysphagia but is most durable in reflux control. The most common side effect of fundoplication is short- term dysphagia , related presumably to tissue oedema and inflammation. It usually resolves within 3 months of surgery. Some patients may experience ‘gas-bloat syndrome’ , especially after a complete fundoplication. Typically, the patient would complain of gaseous distension of the abdomen and failure to belch or vomit , together with an increase in flatulence.</li><li>➤ The mechanism of fundoplication is to create a ‘floppy’ 360 degree wrap around the Gastro-esophageal junction and to restore the angle of His. It has the effect of increasing lower esophageal sphincter (LES) basal pressure, lessening transient lower esophageal sphincter relaxation (TLOSR) and reducing the capacity of the gastric fundus, thereby enhancing gastric emptying.</li><li>➤ The mechanism of fundoplication is to create a ‘floppy’ 360 degree wrap around the Gastro-esophageal junction and to restore the angle of His. It has the effect of increasing lower esophageal sphincter (LES) basal pressure, lessening transient lower esophageal sphincter relaxation (TLOSR) and reducing the capacity of the gastric fundus, thereby enhancing gastric emptying.</li><li>➤ ‘floppy’ 360 degree wrap around the Gastro-esophageal junction</li><li>➤ Complete fundoplication (Nissen) is associated with a higher incidence of short-term dysphagia but is most durable in reflux control.</li><li>➤ Complete fundoplication (Nissen) is associated with a higher incidence of short-term dysphagia but is most durable in reflux control.</li><li>➤ Complete fundoplication (Nissen)</li><li>➤ most durable in reflux control.</li><li>➤ The most common side effect of fundoplication is short- term dysphagia , related presumably to tissue oedema and inflammation. It usually resolves within 3 months of surgery.</li><li>➤ The most common side effect of fundoplication is short- term dysphagia , related presumably to tissue oedema and inflammation. It usually resolves within 3 months of surgery.</li><li>➤ most common side effect</li><li>➤ of fundoplication is</li><li>➤ short- term dysphagia</li><li>➤ Some patients may experience ‘gas-bloat syndrome’ , especially after a complete fundoplication. Typically, the patient would complain of gaseous distension of the abdomen and failure to belch or vomit , together with an increase in flatulence.</li><li>➤ Some patients may experience ‘gas-bloat syndrome’ , especially after a complete fundoplication. Typically, the patient would complain of gaseous distension of the abdomen and failure to belch or vomit , together with an increase in flatulence.</li><li>➤ ‘gas-bloat syndrome’</li><li>➤ failure to belch or vomit</li><li>➤ Ref : Bailey 28 th edition Pg 1116</li><li>➤ Ref : Bailey 28 th edition Pg 1116</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient on screening endoscopy is found to have the below finding incidentally in the middle esophagus. What does the below picture depict?", "options": [{"label": "A", "text": "Achalasia", "correct": false}, {"label": "B", "text": "Varices", "correct": false}, {"label": "C", "text": "Leiomyoma", "correct": true}, {"label": "D", "text": "Zenker's diverticulum", "correct": false}], "correct_answer": "C. Leiomyoma", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/27/screenshot-2023-04-26-123631_LayFHTl.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/image_Bx5s38n.png", "https://cerebellum-web-static.s3.amazonaws.com/media/public/image_veTewLy.jpeg"], "explanation": "<p><strong>Ans. C) Leiomyoma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation :</li><li>• Leiomyomas are the most common solid benign tumours of the esophagus . They are mostly found incidentally as a submucosal mass on endoscopy as seen in the image, but may produce compressive symptoms when large. EUS shows a hypoechoic mass arising from the muscularis propria or the submucosal layer. They rarely become malignant; however, resection is indicated if enlarging on serial assessment. Small leiomyomas can be enucleated with a thoracoscopic approach, keeping the mucosa intact. Pre-operative biopsy or EUS-guided fine-needle aspiration (FNA) is relatively contraindicated as the consequent scarring will increase the chance of breaching the mucosa during enucleation. Endoscopic resection is possible using submucosal tunnelling endoscopic resection (STER); this creates a mucosal opening a short distance from the leiomyoma (3–5 cm proximally), allowing a submucosal tunnel to reach the lesion.</li><li>• Leiomyomas are the most common solid benign tumours of the esophagus . They are mostly found incidentally as a submucosal mass on endoscopy as seen in the image, but may produce compressive symptoms when large.</li><li>• Leiomyomas are the most common solid benign tumours of the esophagus . They are mostly found incidentally as a submucosal mass on endoscopy as seen in the image, but may produce compressive symptoms when large.</li><li>• Leiomyomas are the most common solid benign tumours of the esophagus</li><li>• EUS shows a hypoechoic mass arising from the muscularis propria or the submucosal layer. They rarely become malignant; however, resection is indicated if enlarging on serial assessment.</li><li>• EUS shows a hypoechoic mass arising from the muscularis propria or the submucosal layer. They rarely become malignant; however, resection is indicated if enlarging on serial assessment.</li><li>• Small leiomyomas can be enucleated with a thoracoscopic approach, keeping the mucosa intact. Pre-operative biopsy or EUS-guided fine-needle aspiration (FNA) is relatively contraindicated as the consequent scarring will increase the chance of breaching the mucosa during enucleation.</li><li>• Small leiomyomas can be enucleated with a thoracoscopic approach, keeping the mucosa intact. Pre-operative biopsy or EUS-guided fine-needle aspiration (FNA) is relatively contraindicated as the consequent scarring will increase the chance of breaching the mucosa during enucleation.</li><li>• Pre-operative biopsy or EUS-guided fine-needle aspiration (FNA) is relatively contraindicated as the consequent scarring will increase the chance of breaching the mucosa during enucleation.</li><li>• Endoscopic resection is possible using submucosal tunnelling endoscopic resection (STER); this creates a mucosal opening a short distance from the leiomyoma (3–5 cm proximally), allowing a submucosal tunnel to reach the lesion.</li><li>• Endoscopic resection is possible using submucosal tunnelling endoscopic resection (STER); this creates a mucosal opening a short distance from the leiomyoma (3–5 cm proximally), allowing a submucosal tunnel to reach the lesion.</li><li>• Other options:</li><li>• A: Achalasia: Endoscopy will show narrowing in distal esophagus. Patients present with dysphagia</li><li>• B. Varices: Endoscopy shows venous dilations in a case of portal hypertension with history of hematemesis.</li><li>• D: Zenker’s diverticulum: This will be seen as an outpouching of the mucosa above the cricopharynx. The patient will present with regurgitation and halitosis. Endoscopy will show two lumens- one normal esophageal (blue arrow) and the other of the diverticulum (green arrow).</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Leiomyomas are the most common solid benign tumours of the esophagus.</li><li>➤ Ref : Bailey 28 th Ed. Pg 1134.</li><li>➤ Ref : Bailey 28 th Ed. Pg 1134.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 65-year-old male patient presented with progressive dysphagia to solid foods more than liquid foods and significant weight loss. Barium swallow shows the following: Choose the incorrect statement with respect to the probable diagnosis?", "options": [{"label": "A", "text": "Flexible endoscopy is used to confirm the diagnosis", "correct": false}, {"label": "B", "text": "The barium swallow shows shouldering with rat tail appearance", "correct": false}, {"label": "C", "text": "EUS is the investigation of choice (IOC) to assess tumour invasion", "correct": false}, {"label": "D", "text": "T2 tumour is restricted to submucosa", "correct": true}], "correct_answer": "D. T2 tumour is restricted to submucosa", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/27/screenshot-2023-04-26-123631_wiE363W.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/15/screenshot-2024-03-15-152628.jpg"], "explanation": "<p><strong>Ans. D) T2 tumour is restricted to submucosa</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A. This is correct . Flexible endoscopy with biopsy is the investigation of choice for confirming the diagnosis .</li><li>• Option A.</li><li>• correct</li><li>• Flexible endoscopy with biopsy is the investigation of choice for confirming the diagnosis</li><li>• Option B . This is correct . Barium shows long segment narrowing , abrupt tapering and rat tail appearance of esophagus suggestive of esophageal carcinoma.</li><li>• Option B</li><li>• correct</li><li>• Barium shows long segment narrowing</li><li>• abrupt tapering</li><li>• rat tail appearance of esophagus</li><li>• Option C . This is correct . Depth of invasion is best assessed by Endoscopic ultrasound (EUS).</li><li>• Option C</li><li>• correct</li><li>• Depth of invasion is best assessed by Endoscopic ultrasound</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• While endoscopy with biopsy is used for diagnosis , EUS is for local staging . T2 is tumor invading muscularis .</li><li>• endoscopy with biopsy is used for diagnosis</li><li>• EUS</li><li>• local staging</li><li>• T2 is tumor invading muscularis</li><li>• Esophageal carcinoma is a gastrointestinal tumour with poor prognosis due to late presentation .</li><li>• Esophageal carcinoma is a gastrointestinal tumour with poor prognosis due to late presentation .</li><li>• Esophageal carcinoma</li><li>• gastrointestinal tumour with poor prognosis</li><li>• late presentation</li><li>• Etiology &amp; Risk factors for SCC:</li><li>• Etiology &amp; Risk factors for SCC:</li><li>• Spirits: alcohol Spices Sepsis: HPV Smoking Plummer Vinson syndrome</li><li>• Spirits: alcohol</li><li>• Spices</li><li>• Sepsis: HPV</li><li>• Smoking</li><li>• Plummer Vinson syndrome</li><li>• Risk factors for adenocarcinoma:</li><li>• Risk factors for adenocarcinoma:</li><li>• Barrett's esophagus GERD Smoking Obesity</li><li>• Barrett's esophagus</li><li>• GERD</li><li>• Smoking</li><li>• Obesity</li><li>• Clinical features:</li><li>• Clinical features:</li><li>• Progressive dysphagia is the most common symptom. Early symptoms may include a mild hold-up sensation that, if ignored, will progress from dysphagia to a solid, soft and eventually to a liquid diet. There may often be anorexia, weight loss, odynophagia and regurgitation symptoms. Hoarseness may indicate involvement of recurrent laryngeal nerve of any side . Early cancers are usually asymptomatic and are only picked up on endoscopy performed for other reasons.</li><li>• Progressive dysphagia is the most common symptom. Early symptoms may include a mild hold-up sensation that, if ignored, will progress from dysphagia to a solid, soft and eventually to a liquid diet.</li><li>• There may often be anorexia, weight loss, odynophagia and regurgitation symptoms. Hoarseness may indicate involvement of recurrent laryngeal nerve of any side .</li><li>• Hoarseness may indicate involvement of recurrent laryngeal nerve of any side</li><li>• Early cancers are usually asymptomatic and are only picked up on endoscopy performed for other reasons.</li><li>• TNM classification of oesophageal cancer</li><li>• TNM classification of oesophageal cancer</li><li>• Diagnosis: Flexible endoscopy with biopsy is the investigation of choice for confirming the diagnosis.</li><li>• Diagnosis:</li><li>• Flexible endoscopy</li><li>• biopsy is the investigation of choice</li><li>• Ref : Bailey 28th Ed. Pg 1136-38</li><li>• Ref :</li><li>• Bailey 28th Ed. Pg 1136-38</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the imaging modality in the picture shown?", "options": [{"label": "A", "text": "Chromoendoscopy", "correct": false}, {"label": "B", "text": "Virtual endoscopy", "correct": false}, {"label": "C", "text": "Narrow band imaging", "correct": true}, {"label": "D", "text": "ICG imaging", "correct": false}], "correct_answer": "C. Narrow band imaging", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/27/screenshot-2023-04-26-123631_ITvc20H.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/15/picture1_9pIu6Y2.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/15/screenshot-2024-03-15-153546.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/15/screenshot-2024-03-15-153703.jpg"], "explanation": "<p><strong>Ans. C) Narrow band imaging</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A : Additional chromoendoscopy using different agents , e.g., methylene blue, acetic acid or indigo carmine, could aid diagnosis.”</li><li>• Option A</li><li>• chromoendoscopy using different agents</li><li>• For squamous cell dysplasia and cancer, chromoendoscopy using Lugol’s iodine is a useful adjunct ; the normal squamous mucosa will be stained brown, while dysplastic and early cancer remains unstained.</li><li>• For squamous cell dysplasia and cancer, chromoendoscopy using Lugol’s iodine is a useful adjunct ; the normal squamous mucosa will be stained brown, while dysplastic and early cancer remains unstained.</li><li>• squamous cell dysplasia and cancer, chromoendoscopy</li><li>• Lugol’s iodine</li><li>• useful adjunct</li><li>• normal squamous mucosa</li><li>• Chromoendoscopy with Lugol’s iodine spray</li><li>• Option B : Virtual endoscopy</li><li>• Option B</li><li>• Virtual endoscopy</li><li>• It is a CT scan with reconstruction of GI organ .</li><li>• CT scan with reconstruction of GI organ</li><li>• Option D: ICG imaging : Indocyanine green is injected and using fluorescence , the anatomy or the vascularity of the organ is assessed .</li><li>• Option D:</li><li>• ICG imaging</li><li>• Indocyanine green</li><li>• injected and using fluorescence</li><li>• anatomy or the vascularity of the organ is assessed</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• While NBI is used for assessing submucosal vascularity in Barretts , Chromoendoscopy with spraying of Lugols iodine or Methylene blue will demarcate suspicious areas of tumor on endoscopy.</li><li>• While NBI</li><li>• assessing submucosal vascularity in Barretts</li><li>• Chromoendoscopy with spraying of Lugols iodine</li><li>• Methylene blue</li><li>• demarcate suspicious</li><li>• tumor on endoscopy.</li><li>• Ref : Bailey 28 th Ed. Pg 1120.</li><li>• Ref :</li><li>• Bailey 28 th Ed. Pg 1120.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 40-year-old obese patient undergoes a regular endoscopy during his check-up. The surgeon notices this endoscopic finding. What condition is he suffering from?", "options": [{"label": "A", "text": "Esophageal carcinoma", "correct": false}, {"label": "B", "text": "Sliding hiatus hernia", "correct": true}, {"label": "C", "text": "Rolling hiatus hernia", "correct": false}, {"label": "D", "text": "Diaphragmatic paralysis", "correct": false}], "correct_answer": "B. Sliding hiatus hernia", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/02/screenshot-2023-06-02-120040.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/18/07_VXOii0d.jpg"], "explanation": "<p><strong>Ans. B) Sliding hiatus hernia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Esophageal carcinoma : This would appear as a mass arising from mucosa</li><li>• Option A. Esophageal carcinoma</li><li>• appear as a mass arising from mucosa</li><li>• Option D. Diaphragmatic paralysis : This would appear as an area of raised hemidiaphragm , best seen on CECT.</li><li>• Option D. Diaphragmatic</li><li>• paralysis</li><li>• appear as an area of raised hemidiaphragm</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• A sliding hiatus hernia predisposes to GERD and is usually diagnosed in the presence of reflux symptoms . For asymptomatic patients, it can be an incidental finding on plain chest radiographs or CT as an intrathoracic gas bubble or fluid level.</li><li>• sliding hiatus hernia predisposes to GERD</li><li>• diagnosed in the presence of reflux symptoms</li><li>• Ref : Bailey 28 th Ed. Pg 1117</li><li>• Ref : Bailey 28 th Ed. Pg 1117</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following statements regarding hiatus hernia is false?", "options": [{"label": "A", "text": "The sliding hiatus hernia is the most common type", "correct": false}, {"label": "B", "text": "Increased age is a predisposing factor for hiatus hernia", "correct": false}, {"label": "C", "text": "Type 2 hiatus hernia mainly presents with obstruction symptoms", "correct": false}, {"label": "D", "text": "Sliding hiatus hernia is always symptomatic", "correct": true}], "correct_answer": "D. Sliding hiatus hernia is always symptomatic", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/27/picture1_n5mX23C.png"], "explanation": "<p><strong>Ans. D) Sliding hiatus hernia is always symptomatic.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A . The sliding hernia (type I) - accounting for most hiatus hernias where the OGJ is herniated upwards .</li><li>• Option A</li><li>• The sliding hernia (type I)</li><li>• accounting for most hiatus hernias</li><li>• OGJ is herniated upwards</li><li>• Option B . Increasing age is a risk factor is also true .</li><li>• Option B</li><li>• Increasing age is a risk factor is also true</li><li>• Option C . Type 2 or paraesophageal rolling type presents with obstructive symptoms due to risk of gastric volvulus .</li><li>• Option C</li><li>• Type 2 or paraesophageal rolling type</li><li>• obstructive symptoms due to risk of gastric volvulus</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• While sliding type of hiatus hernia is common , rolling type presents with obstructive symptoms . However, not every hiatus hernia is symptomatic , as some are found incidentally on endoscopy or imaging.</li><li>• sliding type of hiatus hernia is common</li><li>• rolling type</li><li>• obstructive symptoms</li><li>• not every hiatus hernia is symptomatic</li><li>• A hiatus hernia is a condition in which the abdominal contents migrate through the hiatal opening of the diaphragm into the mediastinum.</li><li>• hiatus hernia</li><li>• abdominal contents migrate through the hiatal opening of the diaphragm into the mediastinum.</li><li>• There are four types of hiatus hernia:</li><li>• There are four types of hiatus hernia:</li><li>• The sliding hernia (type I) - accounting for most hiatus hernias where the OGJ is herniated upwards . The true para-esophageal/rolling hernia (type II) - where there is asymmetrical herniation of the stomach next to the esophagus and the OGJ remains in its normal intra-abdominal position . The more common mixed sliding and para-esophageal hernia (type III) When abdominal viscera other than the stomach migrates into the hernia sac, it is classified as type IV.</li><li>• The sliding hernia (type I) - accounting for most hiatus hernias where the OGJ is herniated upwards .</li><li>• The sliding hernia (type I)</li><li>• most hiatus hernias where the OGJ is herniated upwards</li><li>• The true para-esophageal/rolling hernia (type II) - where there is asymmetrical herniation of the stomach next to the esophagus and the OGJ remains in its normal intra-abdominal position .</li><li>• The true para-esophageal/rolling hernia (type II)</li><li>• asymmetrical herniation of the stomach next to the esophagus</li><li>• OGJ remains in its normal intra-abdominal position</li><li>• The more common mixed sliding and para-esophageal hernia (type III)</li><li>• When abdominal viscera other than the stomach migrates into the hernia sac, it is classified as type IV.</li><li>• Hiatus hernia is closely related to advanced age and obesity . It may be missed on endoscopy, hence CT with oral contrast is the confirmatory test.</li><li>• Hiatus hernia</li><li>• closely related to advanced age and obesity</li><li>• Ref : Bailey 28 th Ed. Pg 1117</li><li>• Ref :</li><li>• Bailey 28 th Ed. Pg 1117</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Annual risk of adenocarcinoma in Barrett’s esophagus without dysplasia is?", "options": [{"label": "A", "text": "0.2 to 0.5%", "correct": true}, {"label": "B", "text": "0.7 to 1%", "correct": false}, {"label": "C", "text": "2 to 5%", "correct": false}, {"label": "D", "text": "7 to 10%", "correct": false}], "correct_answer": "A. 0.2 to 0.5%", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) 0.2 to 0.5%</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation :</li><li>• For non-dysplastic Barrett’s , the risk of progression to cancer is around 0.2–0.5% per year. This increases to around 0.7% per year for low-grade dysplasia . For high-grade dysplasia , the risk of cancer progression can be as high as 7%. The Seattle biopsy protocol , which includes four-quadrant random biopsies every 2 cm in addition to targeted biopsies on macroscopically visible lesions, is recommended at the time of diagnosis and subsequent surveillance.</li><li>• For non-dysplastic Barrett’s , the risk of progression to cancer is around 0.2–0.5% per year.</li><li>• For non-dysplastic Barrett’s , the risk of progression to cancer is around 0.2–0.5% per year.</li><li>• non-dysplastic Barrett’s</li><li>• risk of progression to cancer</li><li>• 0.2–0.5% per year.</li><li>• This increases to around 0.7% per year for low-grade dysplasia .</li><li>• This increases to around 0.7% per year for low-grade dysplasia .</li><li>• This increases to around 0.7% per year for low-grade dysplasia</li><li>• For high-grade dysplasia , the risk of cancer progression can be as high as 7%.</li><li>• For high-grade dysplasia , the risk of cancer progression can be as high as 7%.</li><li>• high-grade dysplasia</li><li>• high as 7%.</li><li>• The Seattle biopsy protocol , which includes four-quadrant random biopsies every 2 cm in addition to targeted biopsies on macroscopically visible lesions, is recommended at the time of diagnosis and subsequent surveillance.</li><li>• The Seattle biopsy protocol , which includes four-quadrant random biopsies every 2 cm in addition to targeted biopsies on macroscopically visible lesions, is recommended at the time of diagnosis and subsequent surveillance.</li><li>• Seattle biopsy protocol</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Annual risk of adenocarcinoma in Barrett’s esophagus without dysplasia is 0.2 to 0.5%.</li><li>➤ Ref : Bailey 28 th Ed. Pg 1120</li><li>➤ Ref : Bailey 28 th Ed. Pg 1120</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old male with history of smoking undergoes upper GI endoscopy for recurrent heart-burn. On evaluation, pinkish patches are seen extending from Z line upwards. Biopsy reveals mucous secreting goblet cells with low grade dysplasia. What will be the management of this case?", "options": [{"label": "A", "text": "Surveillance alone", "correct": false}, {"label": "B", "text": "Surveillance (3 to 5 yearly) + PPI", "correct": false}, {"label": "C", "text": "Radiofrequency ablation (RFA) of Barrett's + PPI + Surveillance (6 monthly)", "correct": true}, {"label": "D", "text": "Floppy Nissen fundoplication", "correct": false}], "correct_answer": "C. Radiofrequency ablation (RFA) of Barrett's + PPI + Surveillance (6 monthly)", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Radiofrequency ablation (RFA) of Barrett's + PPI + Surveillance</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A: Surveillance. Surveillance alone may be considered for patients with non-dysplastic Barrett’s esophagus , but for those with confirmed low-grade dysplasia , s urveillance typically requires the addition of medication and removal of dysplastic epithelium due to the increased risk of progression to high-grade dysplasia or adenocarcinoma.</li><li>• Option A: Surveillance.</li><li>• alone may be considered for patients with non-dysplastic Barrett’s esophagus</li><li>• for those with confirmed low-grade dysplasia</li><li>• urveillance</li><li>• addition of medication and removal of dysplastic epithelium</li><li>• Option B: Surveillance (3 to 5 yearly) + PPI. Combining surveillance with proton pump inhibitor (PPI) therapy is a common approach for managing Barrett’s esophagus without dysplasia . PPIs help control acid reflux, which can decrease the inflammatory stimulus for further dysplastic changes.</li><li>• Option B: Surveillance (3 to 5 yearly) + PPI. Combining surveillance</li><li>• proton pump inhibitor</li><li>• common approach for managing Barrett’s esophagus</li><li>• without dysplasia</li><li>• Option D: Floppy Nissen fundoplication. Anti-reflux surgery , such as a floppy Nissen fundoplication, is typically reserved for patients with GERD symptoms that are refractory to medical therapy and is not the standard initial treatment for Barrett’s esophagus with low-grade dysplasia.</li><li>• Option D: Floppy Nissen fundoplication. Anti-reflux surgery</li><li>• floppy Nissen fundoplication,</li><li>• reserved for patients with GERD symptoms</li><li>• refractory to medical therapy</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The management of Barrett’s esophagus with low-grade dysplasia commonly includes surveillance and PPI therapy to control acid reflux , with radiofrequency ablation being an option for eradicating dysplastic tissue.</li><li>➤ management of Barrett’s esophagus with low-grade dysplasia</li><li>➤ surveillance and PPI therapy to control acid reflux</li><li>➤ When Barrett’s esophagus without dysplasia is discovered, the treatment is that of the underlying GERD. Pharmacological therapy generally is the same as treatment of symptomatic GERD patients. Anti-reflux surgery is indicated if it is associated with GERD symptoms not responding to medical management . In patients with dysplastic Barrett’s esophagus without suspicion of invasive cancer, the epithelium can be ablated or resected. Ablative therapy aims to completely eradicate all intestinal metaplasia. When mucosa regenerates after ablation in a non-acidic environment (when a high-dose PPI is prescribed), a ‘neo squamous’ lining is formed. Ablative approaches that are supported by evidence include photodynamic therapy, RFA and cryotherapy. Among these methods, RFA is most preferred . In patients with high-grade dysplastic Barrett’s esophagus, ablative, endoscopic resection and esophagectomy should be considered.</li><li>➤ When Barrett’s esophagus without dysplasia is discovered, the treatment is that of the underlying GERD. Pharmacological therapy generally is the same as treatment of symptomatic GERD patients. Anti-reflux surgery is indicated if it is associated with GERD symptoms not responding to medical management .</li><li>➤ When Barrett’s esophagus without dysplasia is discovered, the treatment is that of the underlying GERD. Pharmacological therapy generally is the same as treatment of symptomatic GERD patients. Anti-reflux surgery is indicated if it is associated with GERD symptoms not responding to medical management .</li><li>➤ Anti-reflux surgery is indicated if it is associated with GERD symptoms not responding to medical management</li><li>➤ In patients with dysplastic Barrett’s esophagus without suspicion of invasive cancer, the epithelium can be ablated or resected. Ablative therapy aims to completely eradicate all intestinal metaplasia. When mucosa regenerates after ablation in a non-acidic environment (when a high-dose PPI is prescribed), a ‘neo squamous’ lining is formed. Ablative approaches that are supported by evidence include photodynamic therapy, RFA and cryotherapy. Among these methods, RFA is most preferred .</li><li>➤ In patients with dysplastic Barrett’s esophagus without suspicion of invasive cancer, the epithelium can be ablated or resected. Ablative therapy aims to completely eradicate all intestinal metaplasia. When mucosa regenerates after ablation in a non-acidic environment (when a high-dose PPI is prescribed), a ‘neo squamous’ lining is formed. Ablative approaches that are supported by evidence include photodynamic therapy, RFA and cryotherapy. Among these methods, RFA is most preferred .</li><li>➤ ‘neo squamous’</li><li>➤ RFA is most preferred</li><li>➤ In patients with high-grade dysplastic Barrett’s esophagus, ablative, endoscopic resection and esophagectomy should be considered.</li><li>➤ In patients with high-grade dysplastic Barrett’s esophagus, ablative, endoscopic resection and esophagectomy should be considered.</li><li>➤ Ref : Bailey 28 th Ed., Pg 1120-21.</li><li>➤ Ref : Bailey 28 th Ed., Pg 1120-21.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Preferred treatment for Type 3 Achalasia on High Resolution Manometry (HRM) is?", "options": [{"label": "A", "text": "POEM with long myotomy", "correct": true}, {"label": "B", "text": "Heller’s Cardiomyotomy", "correct": false}, {"label": "C", "text": "Endoscopic dilation", "correct": false}, {"label": "D", "text": "CCB", "correct": false}], "correct_answer": "A. POEM with long myotomy", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) POEM with long myotomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option B: Heller’s Cardiomyotomy. Heller's myotomy is a surgical procedure that cuts the muscles at the lower end of the esophagus and the top of the stomach to relieve dysphagia . While effective for Type 1 and Type 2 Achalasia, it may be less effective for Type 3 due to the spastic component of the disease.</li><li>• Option B: Heller’s Cardiomyotomy.</li><li>• surgical procedure</li><li>• cuts the muscles at the lower end of the esophagus</li><li>• top of the stomach to relieve dysphagia</li><li>• Option C: Endoscopic dilation. Endoscopic dilation or pneumatic dilation is less effective for Type 3 Achalasia because it does not address the spastic contractions adequately.</li><li>• Option C: Endoscopic dilation.</li><li>• pneumatic dilation is less effective for Type 3 Achalasia</li><li>• Option D: CCB. Calcium Channel Blockers (CCB) can be used to reduce contractions in the esophagus; however, they are generally considered a palliative treatment and are not the primary treatment for any type of Achalasia.</li><li>• Option D: CCB.</li><li>• used to reduce contractions in the esophagus;</li><li>• palliative treatment</li><li>• not the primary treatment</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ For Type 3 Achalasia , which includes a spastic component of the esophagus , POEM with long myotomy is the preferred treatment as it can be customized to extend the myotomy length based on HRM and barium swallow findings, providing relief from dysphagia effectively.</li><li>➤ Type 3 Achalasia</li><li>➤ spastic component of the esophagus</li><li>➤ POEM</li><li>➤ long myotomy is the preferred treatment</li><li>➤ customized to extend the myotomy length</li><li>➤ Laparoscopic Heller’s myotomy is superior to single pneumatic dilatation in efficacy and durability . The surgical outcome is better in types I and II achalasia than in type III. For the latter, a longer extended proximal myotomy is often needed for adequate treatment. In type III achalasia , there is a spastic component at the distal esophagus that responds less well to pneumatic dilatation and Heller’s myotomy. POEM has the advantage in that it can extend the length of the myotomy proximally , tailored to preoperative HRM and barium swallow parameters.</li><li>➤ Laparoscopic Heller’s myotomy is superior to single pneumatic dilatation in efficacy and durability . The surgical outcome is better in types I and II achalasia than in type III. For the latter, a longer extended proximal myotomy is often needed for adequate treatment.</li><li>➤ Laparoscopic Heller’s myotomy is superior to single pneumatic dilatation in efficacy and durability</li><li>➤ In type III achalasia , there is a spastic component at the distal esophagus that responds less well to pneumatic dilatation and Heller’s myotomy. POEM has the advantage in that it can extend the length of the myotomy proximally , tailored to preoperative HRM and barium swallow parameters.</li><li>➤ In type III achalasia</li><li>➤ POEM has the advantage in that it can extend the length of the myotomy proximally</li><li>➤ POEM can also be utilized to treat other types of ‘spastic’ esophageal motility disorders such as distal esophageal spasm and hypercontractile esophagus.</li><li>➤ POEM can also be utilized to treat other types of ‘spastic’ esophageal motility disorders</li><li>➤ However, without any anti-reflux procedure, the incidence of GERD is expectedly higher in POEM .</li><li>➤ However, without any anti-reflux procedure, the incidence of GERD is expectedly higher in POEM .</li><li>➤ However, without any anti-reflux procedure, the incidence of GERD is expectedly higher in POEM</li><li>➤ Ref : Bailey 28 th Ed., Pg 1124.</li><li>➤ Ref :</li><li>➤ Bailey 28 th Ed., Pg 1124.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of these are premalignant conditions for Carcinoma Esophagus except?", "options": [{"label": "A", "text": "Corrosive injury", "correct": false}, {"label": "B", "text": "Schatzki ring", "correct": true}, {"label": "C", "text": "Achalasia cardia", "correct": false}, {"label": "D", "text": "Barrett’s esophagus", "correct": false}], "correct_answer": "B. Schatzki ring", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/15/screenshot-2024-03-15-160311.jpg"], "explanation": "<p><strong>Ans. B) Schatzki ring</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Corrosive injury and Achalasia increase the risk of squamous cell CA, while Barrett’s increases the risk of adenocarcinoma of the esophagus.</li><li>• Corrosive injury and Achalasia increase</li><li>• squamous cell CA,</li><li>• Barrett’s increases</li><li>• adenocarcinoma of the esophagus.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Schatzki ring is not considered a premalignant condition for carcinoma of the esophagus , whereas corrosive injury , achalasia cardia , and Barrett’s esophagus are known to be associated with an increased risk of developing esophageal cancer .</li><li>➤ Schatzki ring</li><li>➤ not considered a premalignant condition for carcinoma of the esophagus</li><li>➤ corrosive injury</li><li>➤ achalasia cardia</li><li>➤ Barrett’s esophagus</li><li>➤ increased risk of developing esophageal cancer</li><li>➤ Ref : Bailey 28 th Ed. Pg 1136.</li><li>➤ Ref : Bailey 28 th Ed. Pg 1136.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 65-year-old smoker male is found to have a mass in lower esophagus. What is the most common symptom of Carcinoma esophagus?", "options": [{"label": "A", "text": "Bleeding", "correct": false}, {"label": "B", "text": "Regurgitation", "correct": false}, {"label": "C", "text": "Progressive dysphagia", "correct": true}, {"label": "D", "text": "Weight loss", "correct": false}], "correct_answer": "C. Progressive dysphagia", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Progressive dysphagia</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 60-year-old man is diagnosed with esophageal carcinoma. Radiological investigations show a 2 cm tumor in the lower part of the esophagus without the involvement of mediastinal lymph nodes. On biopsy, it is found to be a squamous cell carcinoma extending up to the submucosa. There is no distant metastasis. What is the best method for management in this patient?", "options": [{"label": "A", "text": "Surgery +/- Adjuvant chemotherapy", "correct": true}, {"label": "B", "text": "Chemotherapy followed by surgery", "correct": false}, {"label": "C", "text": "Chemoradiation followed by surgery", "correct": false}, {"label": "D", "text": "Endoscopic resection followed by chemoradiation", "correct": false}], "correct_answer": "A. Surgery +/- Adjuvant chemotherapy", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Surgery +/- adjuvant chemotherapy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option B: Chemotherapy followed by surgery. Neoadjuvant chemotherapy followed by surgery may be considered for locally advanced esophageal cancers , often when there is lymph node involvement or a larger primary tumor, to shrink the tumor before surgical resection.</li><li>• Option B: Chemotherapy followed by surgery. Neoadjuvant chemotherapy</li><li>• surgery may be considered for locally advanced esophageal cancers</li><li>• Option C: Chemoradiation followed by surgery. Neoadjuvant chemoradiation therapy followed by surgery is an option for locally advanced esophageal cancer, particularly for patients with T3 or T4 tumors or those with positive lymph nodes (N+).</li><li>• Option C: Chemoradiation followed by surgery. Neoadjuvant chemoradiation therapy</li><li>• Option D: Endoscopic resection followed by chemoradiation. Endoscopic resection may be feasible in T1a tumors. Adjuvant chemoradiation (after surgery) may be indicated if there is concern for residual disease after surgery or in cases where preoperative staging underestimates the extent of the disease.</li><li>• Option D: Endoscopic resection followed by chemoradiation. Endoscopic resection may be feasible in T1a tumors. Adjuvant chemoradiation</li><li>• concern for residual disease after surgery</li><li>• Given the described scenario of a 2 cm squamous cell carcinoma confined to the submucosa without lymph node involvement or distant metastasis (T1b, N0, M0), Option A: Surgery +/- chemotherapy is the most appropriate method for management, as per the answer provided.</li><li>• 2 cm squamous cell carcinoma confined to the submucosa without lymph node involvement or distant metastasis</li><li>• Option A: Surgery +/- chemotherapy</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ For a patient with a small (2 cm), localized squamous cell carcinoma of the esophagus extending to the submucosa without lymph node involvement or distant metastasis , the recommended management is surgical resection with/without chemotherapy.</li><li>➤ small (2 cm), localized squamous cell carcinoma of the esophagus</li><li>➤ submucosa without lymph node involvement or distant metastasis</li><li>➤ Surgical resection consists of esophagectomy along with the removal of the involved lymph nodes . Endoscopic mucosal resection can be considered for smaller tumors that are confined to the esophageal mucosa (T1a). For patients who are medically unfit for surgery or have unresectable tumors, chemoradiation can be considered.</li><li>➤ Surgical resection</li><li>➤ esophagectomy</li><li>➤ removal of the involved lymph nodes</li><li>➤ Endoscopic mucosal resection can be considered for smaller tumors that are confined to the esophageal mucosa (T1a).</li><li>➤ Ref : Bailey 28 th Edition pg 1141.</li><li>➤ Ref : Bailey 28 th Edition pg 1141.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 65-year-old man was diagnosed with esophageal carcinoma. Endoscopic ultrasonography showed a 4 cm mass in the middle esophagus above the aortic arch. Which surgical approach will you use?", "options": [{"label": "A", "text": "Mckeown’s approach", "correct": true}, {"label": "B", "text": "Ivor Lewis approach", "correct": false}, {"label": "C", "text": "Orringer’s approach", "correct": false}, {"label": "D", "text": "Trans hiatal approach", "correct": false}], "correct_answer": "A. Mckeown’s approach", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Mckeown’s approach</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• When choosing the appropriate surgical approach for esophageal carcinoma, the location of the tumor within the esophagus is a crucial determining factor. Let's evaluate the surgical options based on the tumor's described location:</li><li>• Option B: Ivor Lewis approach The Ivor Lewis, or double approach, is mainly used for tumors in the lower third of the esophagus. This technique involves abdominal and thoracic incisions, with the anastomosis created within the chest.</li><li>• Option B: Ivor Lewis approach</li><li>• double approach, is mainly used for tumors in the lower third of the esophagus.</li><li>• Option C: Orringer’s approach Also known as the transhiatal approach , this is generally utilized for tumors of the lower third or middle half of the esophagus . The anastomosis is made in the neck, but the approach avoids thoracic incisions, which might be beneficial for patients with poor pulmonary reserve.</li><li>• Option C: Orringer’s approach</li><li>• transhiatal approach</li><li>• utilized for tumors of the lower third or middle half of the esophagus</li><li>• Option D: Trans hiatal approach This approach is same as Orringer’s and is used for lower third esophageal tumors , with the anastomosis also performed in the neck, without thoracotomy.</li><li>• Option D: Trans hiatal approach</li><li>• same as Orringer’s</li><li>• used for lower third esophageal tumors</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ For esophageal carcinoma located in the middle third of the esophagus , the Mckeown's triple approach is typically the surgical technique of choice , offering optimal exposure for resection and anastomosis.</li><li>➤ esophageal carcinoma</li><li>➤ middle third of the esophagus</li><li>➤ Mckeown's triple approach</li><li>➤ surgical technique of choice</li><li>➤ The 3 main approaches are:</li><li>➤ The 3 main approaches are:</li><li>➤ Mckeown’s (triple) approach: Done for upper 1/3 rd and mid 1/3 rd tumours Anastomosis site is neck Abdominal, thoracic and left neck incisions made Transhiatal approach (Orringer’s) Lower 1/3 rd tumours Anastomosis site in neck Ivor Lewis (double) approach: Lower 1/3 rd esophageal tumours Anastomosis site in thorax</li><li>➤ Mckeown’s (triple) approach: Done for upper 1/3 rd and mid 1/3 rd tumours Anastomosis site is neck Abdominal, thoracic and left neck incisions made</li><li>➤ Mckeown’s (triple) approach:</li><li>➤ Mckeown’s (triple) approach:</li><li>➤ Done for upper 1/3 rd and mid 1/3 rd tumours Anastomosis site is neck Abdominal, thoracic and left neck incisions made</li><li>➤ Done for upper 1/3 rd and mid 1/3 rd tumours</li><li>➤ Done for upper 1/3 rd and mid 1/3 rd tumours</li><li>➤ Anastomosis site is neck</li><li>➤ Anastomosis site is neck</li><li>➤ Abdominal, thoracic and left neck incisions made</li><li>➤ Abdominal, thoracic and left neck incisions made</li><li>➤ Transhiatal approach (Orringer’s) Lower 1/3 rd tumours Anastomosis site in neck</li><li>➤ Transhiatal approach (Orringer’s)</li><li>➤ Transhiatal approach (Orringer’s)</li><li>➤ Lower 1/3 rd tumours Anastomosis site in neck</li><li>➤ Lower 1/3 rd tumours</li><li>➤ Lower 1/3 rd tumours</li><li>➤ Anastomosis site in neck</li><li>➤ Anastomosis site in neck</li><li>➤ Ivor Lewis (double) approach: Lower 1/3 rd esophageal tumours Anastomosis site in thorax</li><li>➤ Ivor Lewis (double) approach:</li><li>➤ Ivor Lewis (double) approach:</li><li>➤ Lower 1/3 rd esophageal tumours Anastomosis site in thorax</li><li>➤ Lower 1/3 rd esophageal tumours</li><li>➤ Lower 1/3 rd esophageal tumours</li><li>➤ Anastomosis site in thorax</li><li>➤ Anastomosis site in thorax</li><li>➤ In esophagectomy, a proximal margin of 10cm and distal margin of 5cms are taken.</li><li>➤ Ref : 28 th edition bailey pg 1143</li><li>➤ Ref : 28 th edition bailey pg 1143</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Palliative options for esophageal carcinoma include stent placement. What is the most common complication of the procedure?", "options": [{"label": "A", "text": "P erforation", "correct": false}, {"label": "B", "text": "I nfection", "correct": false}, {"label": "C", "text": "M igration", "correct": true}, {"label": "D", "text": "O dynophagia", "correct": false}], "correct_answer": "C. M igration", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Migration</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "According to the latest 8 th edition AJCC guidelines, which parameter will you choose for determining the prognosis of esophageal cancer?", "options": [{"label": "A", "text": "Age of patient", "correct": false}, {"label": "B", "text": "T stage", "correct": true}, {"label": "C", "text": "Length of involvement", "correct": false}, {"label": "D", "text": "Site involved", "correct": false}], "correct_answer": "B. T stage", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/15/screenshot-2024-03-15-152628_X0A7OPS.jpg"], "explanation": "<p><strong>Ans. B) T stage</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The T stage , which reflects the depth of tumor invasion , is a crucial parameter in the AJCC staging system for determining the prognosis of esophageal cancer .</li><li>➤ T stage</li><li>➤ reflects the depth of tumor invasion</li><li>➤ crucial parameter in the AJCC staging system</li><li>➤ prognosis of esophageal cancer</li><li>➤ The T stage advances as the tumour invades from mucosa deep to muscle, adventitia and beyond the esophagus . Careful disease staging is essential to guide therapy.</li><li>➤ T stage advances</li><li>➤ tumour invades from mucosa deep to muscle, adventitia</li><li>➤ beyond the esophagus</li><li>➤ Ref : pg 1138, Bailey and Love 28 th ed</li><li>➤ Ref : pg 1138, Bailey and Love 28 th ed</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the below is not an indication for performing the test shown in the image?", "options": [{"label": "A", "text": "Planning anti-reflux surgery", "correct": false}, {"label": "B", "text": "Patients with Barrett’s on endoscopy", "correct": true}, {"label": "C", "text": "Atypical symptoms like cough and asthma", "correct": false}, {"label": "D", "text": "Recurrence despite adequate medications", "correct": false}], "correct_answer": "B. Patients with Barrett’s on endoscopy", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/image_HkUZr7P.png"], "explanation_images": [], "explanation": "<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 40-year-old patient with long-standing history of GERD undergoes endoscopic evaluation. He is found to salmon colored tongue-like projections of the mucosa above the GE junction. What is the diagnosis and next step?", "options": [{"label": "A", "text": "Barrett's esophagus, Biopsy at GE junction", "correct": false}, {"label": "B", "text": "Barrett's esophagus, multiple quadrant biopsies", "correct": true}, {"label": "C", "text": "Esophagitis, 24 hour pH study", "correct": false}, {"label": "D", "text": "Schatzki’s ring, Biopsy", "correct": false}], "correct_answer": "B. Barrett's esophagus, multiple quadrant biopsies", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Barrett esophagus, multiple quadrant biopsies</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Options A and B:</li><li>• Options A and B:</li><li>• Barrett’s esophagus is characterized by the presence of salmon-colored mucosa in the lower esophagus, due to the abnormal columnar epithelium replacing the normal squamous epithelium, often as a result of chronic gastroesophageal reflux disease (GERD). It is diagnosed by multiple 4 quadrant biopsies and 1-2 cm intervals as per Seattle protocol.</li><li>• Option C: GERD, 24 hour pH GERD alone does not involve salmon-colored mucosa as a feature.</li><li>• Option C: GERD, 24 hour pH</li><li>• Option D: Schatzki’s ring, biopsy A Schatzki’s ring is a benign, thin, circumferential constriction in the lower esophagus and does not present with salmon-colored mucosa.</li><li>• Option D: Schatzki’s ring, biopsy</li><li>• The correct answer is Option B: Barrett’s esophagus , with multiple quadrant biopsies which is indeed associated with salmon-colored mucosa in the lower esophagus.</li><li>• Option B: Barrett’s esophagus</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Barrett’s esophagus is identified by the appearance of salmon-colored mucosa in the lower esophagus and is a consequence of chronic GERD . Recognition of this endoscopic finding is critical for the diagnosis and management of Barrett’s esophagus, given its potential for progression to esophageal adenocarcinoma.</li><li>➤ Barrett’s esophagus</li><li>➤ appearance of salmon-colored mucosa</li><li>➤ lower esophagus and is a consequence of chronic GERD</li><li>➤ Barrett’s esophagus is a known complication of GERD. It is the proximal migration of columnar epithelium (salmon-coloured mucosa) in the lower esophagus extending more than 1 cm above the Gastro-esophageal Junction. The additional criterion of the biopsy-proven presence of mucus-secreting goblet cells or intestinal metaplasia is controversial.</li><li>➤ Barrett’s esophagus is a known complication of GERD. It is the proximal migration of columnar epithelium (salmon-coloured mucosa) in the lower esophagus extending more than 1 cm above the Gastro-esophageal Junction. The additional criterion of the biopsy-proven presence of mucus-secreting goblet cells or intestinal metaplasia is controversial.</li><li>➤ Barrett’s esophagus is a known complication of GERD. It is the proximal migration of columnar epithelium (salmon-coloured mucosa) in the lower esophagus extending more than 1 cm above the Gastro-esophageal Junction. The additional criterion of the biopsy-proven presence of mucus-secreting goblet cells or intestinal metaplasia is controversial.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 70-year-old woman presents with dysphagia and generalized weakness for 3 months. Peripheral blood smear revealed hypochromic, microcytic anemia. A contrast imaging was done which revealed the following clinical picture. What about the following condition is incorrect?", "options": [{"label": "A", "text": "Dysphagia is due to the presence of a post-cricoid web.", "correct": false}, {"label": "B", "text": "Myotomy is done to dilate the webs.", "correct": true}, {"label": "C", "text": "Correcting the Iron deficiency anemia (IDA) may improve dysphagia and pain", "correct": false}, {"label": "D", "text": "It’s a pre malignant condition", "correct": false}], "correct_answer": "B. Myotomy is done to dilate the webs.", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/27/screenshot-2023-04-26-123631_AcyAjOO.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/01/surgery-31.jpg"], "explanation": "<p><strong>Ans. B) Myotomy is done to dilate the webs</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation :</li><li>• Option A: Dysphagia is due to the presence of a post-cricoid web. True . Dysphagia in Plummer Vinson syndrome is typically due to the presence of an esophageal web, often located post-cricoidally.</li><li>• Option A: Dysphagia is due to the presence of a post-cricoid web. True</li><li>• Option C: Correcting the IDA may improve dysphagia and pain. True . Correcting iron deficiency anemia (IDA) can lead to an improvement in dysphagia and pain in patients with Plummer Vinson syndrome.</li><li>• Option C: Correcting the IDA may improve dysphagia and pain. True</li><li>• Option D: It’s a pre malignant condition. True . Plummer Vinson syndrome is associated with an increased risk of hypopharyngeal and upper esophageal squamous cell carcinoma.</li><li>• Option D: It’s a pre malignant condition. True</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The correct management of esophageal webs in Plummer Vinson syndrome involves dilation with bougies or dilators , not myotomy . Addressing underlying iron deficiency anemia can also improve symptoms.</li><li>➤ correct management of esophageal webs in Plummer Vinson syndrome involves dilation with bougies</li><li>➤ dilators</li><li>➤ not myotomy</li><li>➤ It is also called sideropenic dysphagia.</li><li>➤ It is also called sideropenic dysphagia.</li><li>➤ It denotes the presence of a post-cricoid web that is associated with the following:</li><li>➤ Iron-deficiency anemia Glossitis Koilonychia Some patients may have oropharyngeal leukoplakia, and this may account for an alleged increased risk of developing hypopharyngeal cancer.</li><li>➤ Iron-deficiency anemia</li><li>➤ Iron-deficiency anemia</li><li>➤ Glossitis</li><li>➤ Glossitis</li><li>➤ Koilonychia</li><li>➤ Koilonychia</li><li>➤ Some patients may have oropharyngeal leukoplakia, and this may account for an alleged increased risk of developing hypopharyngeal cancer.</li><li>➤ Some patients may have oropharyngeal leukoplakia, and this may account for an alleged increased risk of developing hypopharyngeal cancer.</li><li>➤ Ref : Bailey and love 27 th ed: pg 1105</li><li>➤ Ref : Bailey and love 27 th ed: pg 1105</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the mismatch classification and score from below:", "options": [{"label": "A", "text": "Los Angeles - Severity of GERD on endoscopy", "correct": false}, {"label": "B", "text": "Eckhardt - Severity of GERD based on symptoms", "correct": true}, {"label": "C", "text": "Chicago - Types of Achalasia based on manometry", "correct": false}, {"label": "D", "text": "Prague - Diagnosis of Barrett’s", "correct": false}], "correct_answer": "B. Eckhardt - Severity of GERD based on symptoms", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Eckhardt - Severity of GERD based on symptoms.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A. Los Angeles - Severity of GERD on endoscopy : This refers to the Los Angeles Classification System , which grades the severity of esophagitis based on endoscopic findings , such as the presence and extent of erosions or ulcerations in the esophagus. It's a suitable match.</li><li>• Option A. Los Angeles</li><li>• Severity of GERD on endoscopy</li><li>• Los Angeles Classification System</li><li>• grades the severity of esophagitis based on endoscopic findings</li><li>• Option C. Chicago - Types of Achalasia based on manometry: The Chicago Classification System is used to categorize esophageal motility disorders , including achalasia, based on findings from esophageal manometry . This system identifies different types of achalasia and other motility disorders based on characteristic patterns of esophageal muscle dysfunction. This option is also a suitable match.</li><li>• Option C. Chicago</li><li>• Types of Achalasia based on manometry:</li><li>• Chicago Classification System is used to categorize esophageal motility disorders</li><li>• achalasia, based on findings from esophageal manometry</li><li>• Option D. Prague - Diagnosis of Barrett's : The Prague C &amp; M Criteria are used to standardize the endoscopic evaluation and reporting of Barrett's esophagus . These criteria involve assessing the length and circumferential extent of the Barrett's segment.</li><li>• Option D. Prague</li><li>• Diagnosis of Barrett's</li><li>• standardize the endoscopic evaluation and reporting of Barrett's esophagus</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Los Angeles classification - Severity of GERD on endoscopy</li><li>• Los Angeles classification</li><li>• Chicago classification - Types of Achalasia based on manometry.</li><li>• Chicago classification</li><li>• -</li><li>• Prague classification - Diagnosis of Barrett's</li><li>• Prague</li><li>• classification - Diagnosis of Barrett's</li><li>• Eckhardt score - severity of Achalasia</li><li>• Eckhardt score</li><li>• Ref : Bailey 28 th Ed. Pg 1122.</li><li>• Ref :</li><li>• Bailey 28 th Ed. Pg 1122.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is correct about hiatus hernia?", "options": [{"label": "A", "text": "Best seen on upper GI endoscopy", "correct": false}, {"label": "B", "text": "Mixed type involves upward migration of GE junction", "correct": true}, {"label": "C", "text": "Rolling type is commonly linked to GERD", "correct": false}, {"label": "D", "text": "Surgical management is rarely required", "correct": false}], "correct_answer": "B. Mixed type involves upward migration of GE junction", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Mixed type involves upward migration of GE junction</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A. Best seen on upper GI endoscopy : This statement is incorrect . Hiatus hernias, especially smaller ones, may be missed during upper gastrointestinal (GI) endoscopy. CT with oral contrast is the preferred modality for diagnosis.</li><li>• Option A. Best seen on upper GI endoscopy</li><li>• incorrect</li><li>• Option C. Rolling type is commonly linked to GERD : This statement is incorrect . A rolling (or paraesophageal) hiatus hernia involves the stomach herniating through the esophageal hiatus alongside the GE junction, typically resulting in a \"rolled\" appearance of the gastric fundus. This typically presents with obstructive symptoms.</li><li>• Option C. Rolling type is commonly linked to GERD</li><li>• incorrect</li><li>• Option D. Surgical management is rarely required : This statement is generally incorrect . While smaller hiatus hernias may not always require surgical intervention, larger or symptomatic hernias often necessitate surgical repair, especially if they cause significant symptoms like reflux, chest pain, or difficulty swallowing.</li><li>• Option D. Surgical management is rarely required</li><li>• incorrect</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Both sliding (type 1) and mixed (type 3) hiatus hernias are associated with migration of GE junction . CT with contrast is diagnostic , and surgery is required for larger or symptomatic hiatus hernias .</li><li>➤ Both sliding</li><li>➤ mixed</li><li>➤ hiatus hernias</li><li>➤ migration of GE junction</li><li>➤ CT with contrast is diagnostic</li><li>➤ required for larger or symptomatic hiatus hernias</li><li>➤ Ref : Bailey 28 th Ed. Pg 1117-1118.</li><li>➤ Ref :</li><li>➤ Bailey 28 th Ed. Pg 1117-1118.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is incorrect about achalasia?", "options": [{"label": "A", "text": "Proximal esophagus shows ineffective peristalsis", "correct": false}, {"label": "B", "text": "Heller’s myotomy is ideal for all types of achalasia", "correct": true}, {"label": "C", "text": "Epiphrenic diverticula are associated with achalasia", "correct": false}, {"label": "D", "text": "Weight loss is included in triad of achalasia", "correct": false}], "correct_answer": "B. Heller’s myotomy is ideal for all types of achalasia", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Heller’s myotomy is ideal for all types of achalasia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A. Proximal esophagus shows ineffective peristalsis : This statement is correct . In achalasia, the primary motor abnormality is the loss of esophageal peristalsis, particularly in the lower esophagus. Instead of the coordinated contractions that propel food downward, there is a lack of effective peristalsis, leading to impaired esophageal emptying.</li><li>• Option A. Proximal esophagus shows ineffective peristalsis</li><li>• correct</li><li>• Option C. Epiphrenic diverticula are associated with achalasia : This statement is correct . Epiphrenic diverticula, which are outpouchings of the esophageal wall located in the lower part of the esophagus, are often associated with achalasia. These diverticula develop due to increased pressure in the distal esophagus resulting from the impaired relaxation of the lower esophageal sphincter characteristic of achalasia.</li><li>• Option C. Epiphrenic diverticula are associated with achalasia</li><li>• correct</li><li>• Option D. Weight loss is included in the Eckhardt severity score : This statement is correct . Eckhardt score includes weight loss, dysphagia, regurgitation and retrosternal pain.</li><li>• Option D. Weight loss is included in the Eckhardt severity score</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Achalasia is a motility disorder characterised by tight lower esophageal sphincter (LES) and ineffective peristalsis . Heller’s myotomy is the preferred treatment, except in type 3 achalasia where POEM is preferred.</li><li>➤ Achalasia is a motility disorder</li><li>➤ tight lower esophageal sphincter</li><li>➤ ineffective peristalsis</li><li>➤ Heller’s myotomy</li><li>➤ Ref : Bailey 28 th Ed. Pg 1121-24.</li><li>➤ Ref :</li><li>➤ Bailey 28 th Ed. Pg 1121-24.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A male child presented with non-bilious vomiting at 3 weeks of age. An X ray was taken that shows the following: What is false regarding the above condition?", "options": [{"label": "A", "text": "Child may present with dehydration in late stages", "correct": false}, {"label": "B", "text": "Olive-shaped palpable mass is best felt when the baby is crying", "correct": true}, {"label": "C", "text": "Peristalsis from left to right side of abdomen may be seen on feeding", "correct": false}, {"label": "D", "text": "Treatment involves Ramstead’s pyloromyotomy", "correct": false}], "correct_answer": "B. Olive-shaped palpable mass is best felt when the baby is crying", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/27/screenshot-2023-04-26-123631_P41XGIF.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B) Olive shaped palpable mass is best felt when the baby is crying</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Child may present with dehydration in late stages . True . Late presentation of pyloric stenosis often results in dehydration and weight loss due to persistent vomiting and loss of gastric secretions.</li><li>• Option A: Child may present with dehydration in late stages</li><li>• True</li><li>• Option C: Peristalsis from left to right side of abdomen may be seen on feeding . True . Visible peristalsis may be observed as the stomach tries to force contents through the narrowed pyloric channel, moving from left to right across the abdomen during or after feeding.</li><li>• Option C: Peristalsis from left to right side of abdomen may be seen on feeding</li><li>• True</li><li>• Option D: Treatment involves Ramsted’s pyloromyotomy . True . Ramstedt's pyloromyotomy is the treatment of choice for pyloric stenosis, which involves splitting the muscle of the pylorus to relieve the obstruction.</li><li>• Option D: Treatment involves Ramsted’s pyloromyotomy</li><li>• True</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The hallmark of pyloric stenosis is non-bilious projectile vomiting in an infant , often leading to a palpable olive-shaped mass in the right upper quadrant when the baby is relaxed . The standard treatment is Ramstedt’s pyloromyotomy.</li><li>➤ pyloric stenosis is non-bilious projectile vomiting in an infant</li><li>➤ palpable olive-shaped mass</li><li>➤ right upper quadrant</li><li>➤ baby is relaxed</li><li>➤ Ramstedt’s pyloromyotomy.</li><li>➤ Olive shaped mass is palpated best as a mass when the child is relaxed (feeding) in the right upper quadrant. Pyloric stenosis presents with non-bilious projectile vomiting starting between 2 and 6 weeks of age. If the presentation is early, clinical findings are unremarkable; if late, weight loss and dehydration requiring resuscitation predominate. The diagnosis is made on a test feed or on abdominal ultrasound showing a thickened and lengthened pylorus. During test feeds, gastric peristalsis is seen passing from left to right across the abdomen, and in a relaxed (feeding) baby, the pyloric ‘tumor’ is palpable as an ‘olive’ in the right upper quadrant . Loss of gastric acid causes a hypochloremic, hypokalemic alkalosis and correction may take 24–48 hours. Ramstedt pyloromyotomy is performed laparoscopically or through a supraumbilical or right upper quadrant incision.</li><li>➤ Olive shaped mass is palpated best as a mass when the child is relaxed (feeding) in the right upper quadrant.</li><li>➤ Olive shaped mass is palpated best as a mass when the child is relaxed (feeding) in the right upper quadrant.</li><li>➤ Pyloric stenosis presents with non-bilious projectile vomiting starting between 2 and 6 weeks of age. If the presentation is early, clinical findings are unremarkable; if late, weight loss and dehydration requiring resuscitation predominate.</li><li>➤ The diagnosis is made on a test feed or on abdominal ultrasound showing a thickened and lengthened pylorus. During test feeds, gastric peristalsis is seen passing from left to right across the abdomen, and in a relaxed (feeding) baby, the pyloric ‘tumor’ is palpable as an ‘olive’ in the right upper quadrant .</li><li>➤ test feed or on abdominal ultrasound</li><li>➤ relaxed (feeding) baby, the pyloric ‘tumor’ is palpable as an ‘olive’ in the right upper quadrant</li><li>➤ Loss of gastric acid causes a hypochloremic, hypokalemic alkalosis and correction may take 24–48 hours.</li><li>➤ hypochloremic, hypokalemic alkalosis</li><li>➤ Ramstedt pyloromyotomy is performed laparoscopically or through a supraumbilical or right upper quadrant incision.</li><li>➤ Ref : Bailey and Love 28 th edition: pg 259</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th edition: pg 259</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Metabolic abnormalities seen in infantile pyloric stenosis are all except?", "options": [{"label": "A", "text": "Renal hypokalemia", "correct": false}, {"label": "B", "text": "Metabolic alkalosis", "correct": false}, {"label": "C", "text": "Paradoxical aciduria", "correct": false}, {"label": "D", "text": "Hypocalcemia", "correct": true}], "correct_answer": "D. Hypocalcemia", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Hypocalcemia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• When assessing the metabolic abnormalities associated with infantile pyloric stenosis , it's important to understand the typical biochemical disturbances resulting from the condition:</li><li>• metabolic abnormalities</li><li>• infantile pyloric stenosis</li><li>• typical biochemical disturbances</li><li>• Option A: Renal hypokalemia . True . The persistent vomiting associated with pyloric stenosis leads to a significant loss of stomach acids , which are rich in hydrogen and chloride ions . The body compensates by increasing renal excretion of potassium (K+) and hydrogen ions (H+), leading to hypokalemia.</li><li>• Option A: Renal hypokalemia</li><li>• True</li><li>• persistent vomiting</li><li>• pyloric stenosis leads to a significant loss of stomach acids</li><li>• rich in hydrogen and chloride ions</li><li>• Option B: Metabolic alkalosis . True . The loss of gastric acid through vomiting can lead to a primary metabolic alkalosis .</li><li>• Option B: Metabolic alkalosis</li><li>• True</li><li>• loss of gastric acid</li><li>• vomiting</li><li>• primary metabolic alkalosis</li><li>• Option C: Paradoxical aciduria . True . Despite the systemic alkalosis , the urine may be acidic (paradoxical aciduria) due to the kidney's excretion of H+ ions in an attempt to conserve Na+ due to RAAS activation.</li><li>• Option C: Paradoxical aciduria</li><li>• True</li><li>• systemic alkalosis</li><li>• urine may be acidic</li><li>• kidney's excretion of H+ ions</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The typical metabolic derangement in infantile pyloric stenosis is hypochloremic, hypokalemic alkalosis with paradoxical aciduria . Hypocalcemia is not a common finding associated with this condition.</li><li>➤ metabolic derangement</li><li>➤ infantile pyloric stenosis</li><li>➤ hypochloremic, hypokalemic alkalosis</li><li>➤ paradoxical aciduria</li><li>➤ Hypocalcemia</li><li>➤ not a common finding</li><li>➤ Loss of gastric acid causes a hypochloremic, hypokalemic alkalosis and correction may take 24–48 hours ; 0.9% saline with 0.15% KCl in 5% glucose given at 6–7.5 mL/kg/h provides maintenance and corrects deficits in most babies. As the chloride deficit is replaced , the kidneys correct the pH . Dehydration leads to activation of RAAS in kidneys leading to Na + reabsorption and loss of urinary K + and H + losses (renal hypokalemia and paradoxical aciduria).</li><li>➤ Loss of gastric acid causes a hypochloremic, hypokalemic alkalosis and correction may take 24–48 hours ; 0.9% saline with 0.15% KCl in 5% glucose given at 6–7.5 mL/kg/h provides maintenance and corrects deficits in most babies.</li><li>➤ Loss of gastric acid</li><li>➤ hypochloremic, hypokalemic alkalosis</li><li>➤ correction may take 24–48 hours</li><li>➤ As the chloride deficit is replaced , the kidneys correct the pH .</li><li>➤ chloride deficit is replaced</li><li>➤ kidneys correct the pH</li><li>➤ Dehydration leads to activation of RAAS in kidneys leading to Na + reabsorption and loss of urinary K + and H + losses (renal hypokalemia and paradoxical aciduria).</li><li>➤ (renal hypokalemia and paradoxical aciduria).</li><li>➤ Ref : Bailey 28 th Ed. Pg 259.</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 259.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "What is the procedure being shown below?", "options": [{"label": "A", "text": "Billroth- I reconstruction", "correct": false}, {"label": "B", "text": "Billroth II reconstruction", "correct": true}, {"label": "C", "text": "Braun anastomosis", "correct": false}, {"label": "D", "text": "Roux-en Y gastrojejunostomy", "correct": false}], "correct_answer": "B. Billroth II reconstruction", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/02/backup_of_backup_of_surgery-2-1.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/02/backup_of_backup_of_surgery-20.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/15/screenshot-2024-03-15-191820.jpg"], "explanation": "<p><strong>Ans. B) Billroth II reconstruction</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. This is a procedure where the distal part of the stomach is removed , and the remaining portion of the stomach is directly connected to the duodenum . This option is not depicted in the image.</li><li>• Option A.</li><li>• procedure</li><li>• distal part of the stomach is removed</li><li>• remaining portion of the stomach is directly connected to the duodenum</li><li>• Option C: Braun anastomosis A modification of the Billroth II procedure , where a side-to-side anastomosis between the afferent and efferent loops of the jejunum is performed to reduce bile reflux into the stomach.</li><li>• Option C: Braun anastomosis</li><li>• modification of the Billroth II procedure</li><li>• side-to-side anastomosis between the afferent and efferent loops of the jejunum is performed</li><li>• Option D: Roux-en-Y gastrojejunostomy In this procedure, the jejunum is divided, and the distal part is connected to the stomach to form the gastrojejunostomy, with the proximal end connected back to the jejunum further down to form a \"Y\" shape . This is not depicted in the image.</li><li>• Option D: Roux-en-Y gastrojejunostomy</li><li>• jejunum is divided, and the distal part is connected to the stomach to form the gastrojejunostomy,</li><li>• proximal end connected back to the jejunum</li><li>• form a \"Y\" shape</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Billroth II reconstruction is a surgical technique for gastric resection where the remaining portion of the stomach is anastomosed to the jejunum , usually in a retro-colic fashion , to re-establish gastrointestinal continuity following the removal of part of the stomach . This procedure is indicated for various conditions, including peptic ulcer disease and gastric cancer, and is depicted by the anastomosis of the greater curve of the stomach to the jejunum, bypassing the duodenum.</li><li>➤ Billroth II reconstruction</li><li>➤ surgical technique for gastric resection</li><li>➤ remaining portion of the stomach is anastomosed to the jejunum</li><li>➤ retro-colic fashion</li><li>➤ re-establish gastrointestinal continuity following the removal of part of the stomach</li><li>➤ Billroth I gastrectomy: The lower half of the stomach is removed , and the cut end of the stomach is anastomosed to the first part of the duodenum.</li><li>➤ Billroth I gastrectomy:</li><li>➤ lower half of the stomach is removed</li><li>➤ Billroth II gastrectomy: Following resection, the distal end of the stomach is narrowed by the closure of the lesser curve aspect of the remnant . The greater curve aspect is then anastomosed to the jejunum.</li><li>➤ Billroth II gastrectomy:</li><li>➤ distal end of the stomach is narrowed by the closure of the lesser curve aspect of the remnant</li><li>➤ Roux-en-Y gastrojejunostomy</li><li>➤ Roux-en-Y gastrojejunostomy</li><li>➤ Roux-en Y GJ: Jejunum is divided, distal jejunum is joined to stomach (Roux limb) , proximal divided jejunum is joined to distal jejunum as shown in a Y configuration (image above).</li><li>➤ Roux-en Y GJ:</li><li>➤ Jejunum is divided, distal jejunum is joined to stomach</li><li>➤ (Roux limb)</li><li>➤ Braun modification of classical Billroth II gastrectomy: Billroth II reconstruction with side to side jejunojejunostomy.</li><li>➤ Braun modification of classical Billroth II gastrectomy:</li><li>➤ Braun’s anastomosis</li><li>➤ Braun’s anastomosis</li><li>➤ Ref : Bailey 28 th Ed. Pg 1160, 1163.</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 1160, 1163.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these procedures for peptic ulcers carries the lowest recurrence rate?", "options": [{"label": "A", "text": "Truncal vagotomy with pyloroplasty", "correct": false}, {"label": "B", "text": "Selective vagotomy with pyloroplasty", "correct": false}, {"label": "C", "text": "Highly selective Vagotomy", "correct": false}, {"label": "D", "text": "Truncal vagotomy with antrectomy", "correct": true}], "correct_answer": "D. Truncal vagotomy with antrectomy", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/15/screenshot-2024-03-15-192715.jpg"], "explanation": "<p><strong>Ans. D) Truncal vagotomy with antrectomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Truncal vagotomy with pyloroplasty Involves cutting the main trunk of the vagus nerve to decrease acid secretion and a pyloroplasty to facilitate gastric emptying . Recurrence rates for ulcers can vary from 2 to 7%.</li><li>• Option A: Truncal vagotomy with pyloroplasty</li><li>• cutting the main trunk of the vagus nerve</li><li>• decrease acid secretion and a pyloroplasty to facilitate gastric emptying</li><li>• Option B: Selective vagotomy with pyloroplasty Selective vagotomy targets the nerves supplying the stomach only , sparing those to other abdominal organs like liver , combined with pyloroplasty . This has a slightly higher recurrence rate of 5 to 10%.</li><li>• Option B: Selective vagotomy with pyloroplasty</li><li>• targets the nerves supplying the stomach only</li><li>• sparing those to other abdominal organs like liver</li><li>• pyloroplasty</li><li>• Option C: Highly selective Vagotomy (HSV) Also known as parietal cell vagotomy or proximal gastric vagotomy , HSV selectively denervates the acid-producing part of the stomach without a drainage procedure. Recurrence rates range from 2 to 10%.</li><li>• Option C: Highly selective Vagotomy (HSV)</li><li>• parietal cell vagotomy</li><li>• proximal gastric vagotomy</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In the surgical management of peptic ulcers , truncal vagotomy with antrectomy is associated with the lowest recurrence rate of around 1%. However, it is important to balance this with the procedure's side effect profile, which can be poor compared to highly selective vagotomy, which has fewer side effects.</li><li>➤ surgical management of peptic ulcers</li><li>➤ truncal vagotomy with antrectomy</li><li>➤ lowest recurrence rate of around 1%.</li><li>➤ Recurrence rates after surgery for peptic ulcer:</li><li>➤ Truncal vagotomy with pyloroplasty - 2 to 7% Selective vagotomy with pyloroplasty - 5 to 10% Highly selective Vagotomy - 2 to 10% Truncal vagotomy with antrectomy - 1%</li><li>➤ Truncal vagotomy with pyloroplasty - 2 to 7%</li><li>➤ 2 to 7%</li><li>➤ Selective vagotomy with pyloroplasty - 5 to 10%</li><li>➤ 5 to 10%</li><li>➤ Highly selective Vagotomy - 2 to 10%</li><li>➤ 2 to 10%</li><li>➤ Truncal vagotomy with antrectomy - 1%</li><li>➤ 1%</li><li>➤ Though truncal vagotomy with antrectomy has the least recurrence rate, its side effect profile is poor (10 to 20%) compared to HSV &lt;5% .</li><li>➤ HSV &lt;5%</li><li>➤ Ref : Bailey 28 th Ed. Pg 1161.</li><li>➤ Ref :</li><li>➤ Bailey 28 th Ed. Pg 1161.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient present with acute onset of chest discomfort followed by hematemesis. He has a history of binge drinking and multiple episodes of vomiting. What is the likely diagnosis?", "options": [{"label": "A", "text": "Gastric antral vascular ectasia", "correct": false}, {"label": "B", "text": "Mallory Weiss tear", "correct": true}, {"label": "C", "text": "Boerhaave syndrome", "correct": false}, {"label": "D", "text": "Dieulafoy lesion", "correct": false}], "correct_answer": "B. Mallory Weiss tear", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Mallory Weiss tear</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Gastric antral vascular ectasia (GAVE) . GAVE, also known as watermelon stomach , is a condition characterized by red streaks of dilated vessels in the antrum of the stomach . It does not typically present with acute chest discomfort or follow a history of vomiting.</li><li>• Option A: Gastric antral vascular ectasia (GAVE)</li><li>• watermelon stomach</li><li>• red streaks of dilated vessels</li><li>• antrum of the stomach</li><li>• Option C: Boerhaave syndrome . Boerhaave syndrome is a spontaneous esophageal rupture due to forceful vomiting . It presents with severe chest pain, vomiting, and signs of mediastinal or subcutaneous emphysema. It is a more severe condition than a Mallory-Weiss tear and can be life-threatening. Hematemesis is not typically seen.</li><li>• Option C: Boerhaave syndrome</li><li>• spontaneous esophageal rupture</li><li>• forceful vomiting</li><li>• severe chest pain, vomiting, and signs of mediastinal or subcutaneous emphysema.</li><li>• Option D: Dieulafoy's lesion . A Dieulafoy's lesion is a rare, aberrant, large caliber artery in the stomach wall that bleeds intermittently and can cause significant gastrointestinal hemorrhage. It is not typically associated with vomiting or chest discomfort.</li><li>• Option D: Dieulafoy's lesion</li><li>• rare, aberrant, large caliber artery</li><li>• stomach wall</li><li>• bleeds intermittently</li><li>• cause significant gastrointestinal hemorrhage.</li><li>• Given the patient's history of binge drinking and multiple episodes of vomiting followed by hematemesis and chest discomfort , the most likely diagnosis is Option B: Mallory-Weiss tear .</li><li>• binge drinking</li><li>• multiple episodes of vomiting</li><li>• hematemesis</li><li>• chest discomfort</li><li>• Option B: Mallory-Weiss tear</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ A Mallory-Weiss tear is a laceration of the mucosa near the gastroesophageal junction often caused by forceful vomiting , which can result in hematemesis and is usually managed conservatively with endoscopic interventions.</li><li>➤ Mallory-Weiss tear</li><li>➤ laceration of the mucosa</li><li>➤ gastroesophageal junction often caused by forceful vomiting</li><li>➤ Mallory Weiss tear:</li><li>➤ Mallory Weiss tear:</li><li>➤ Forceful vomiting may lead to a tear of the mucosa/submucosa at the Gastro-esophageal junction, mostly immediately below the squamocolumnar junction (gastric cardia). Patients present with hematemesis. Patients present with acute onset of chest discomfort or odynophagia . When the dissection or hematoma is confined to the esophageal wall, treatment is conservative. Endoscopically, the bleeding can be stopped by adrenaline (epinephrine) injection or endoscopic clips to stop bleeding and close the mucosal defect. Angiographic embolization, if endoscopy fails</li><li>➤ Forceful vomiting may lead to a tear of the mucosa/submucosa at the Gastro-esophageal junction, mostly immediately below the squamocolumnar junction (gastric cardia). Patients present with hematemesis. Patients present with acute onset of chest discomfort or odynophagia .</li><li>➤ acute onset of</li><li>➤ chest discomfort or odynophagia</li><li>➤ When the dissection or hematoma is confined to the esophageal wall, treatment is conservative. Endoscopically, the bleeding can be stopped by adrenaline (epinephrine) injection or endoscopic clips to stop bleeding and close the mucosal defect.</li><li>➤ Endoscopically, the bleeding can be stopped by adrenaline (epinephrine) injection or endoscopic clips</li><li>➤ Angiographic embolization, if endoscopy fails</li><li>➤ Ref : Bailey and Love 28 th edition pg 1129.</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th edition pg 1129.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A woman underwent a gastrectomy procedure 5 months ago for the presence of a gastric ulcer. She now complains of exertional breathlessness. Her blood picture is as follows: What supplements do you think she needs?", "options": [{"label": "A", "text": "Iron", "correct": true}, {"label": "B", "text": "Calcium", "correct": false}, {"label": "C", "text": "Cobalamin", "correct": false}, {"label": "D", "text": "Folic acid", "correct": false}], "correct_answer": "A. Iron", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/02/untitled-176.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. A) Iron</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Calcium . False. While calcium absorption can be affected by gastrectomy due to alterations in the digestive process and the need for vitamin D , the blood picture provided does not specifically suggest a calcium deficiency.</li><li>• Option B: Calcium</li><li>• calcium absorption can be affected by gastrectomy due to alterations in the digestive process and the need for vitamin D</li><li>• Option C: Cobalamin (Vitamin B12) . False. Vitamin B12 deficiency anemia typically presents as macrocytic anemia, with larger than normal red blood cells . However, vitamin B12 deficiency is a concern after gastrectomy due to the loss of intrinsic factor produced by the stomach, which is necessary for vitamin B12 absorption. It usually takes longer to develop after surgery due to large body stores of vitamin B12.</li><li>• Option C: Cobalamin (Vitamin B12)</li><li>• deficiency anemia typically presents as macrocytic anemia, with larger than normal red blood cells</li><li>• Option D: Folic acid . False. Folic acid deficiency also typically presents with macrocytic anemia, not microcytic anemia . It is less likely to be immediately deficient following gastrectomy compared to iron.</li><li>• Option D: Folic acid</li><li>• Folic acid deficiency</li><li>• presents with macrocytic anemia, not microcytic anemia</li><li>• Given that the blood picture shows features suggestive of iron deficiency anemia, the correct supplement needed is Option A: Iron .</li><li>• Option A: Iron</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ After gastrectomy , patients are at an increased risk for iron deficiency anemia due to reduced absorption . Supplementing with iron can help correct the anemia and improve symptoms such as exertional breathlessness.</li><li>➤ After gastrectomy</li><li>➤ increased risk for iron deficiency anemia</li><li>➤ reduced absorption</li><li>➤ Supplementing</li><li>➤ iron can help correct the anemia</li><li>➤ improve symptoms such as exertional breathlessness.</li><li>➤ Complications of gastrectomy:</li><li>➤ Complications of gastrectomy:</li><li>➤ Dumping syndrome ( early and late) Diarrhea Duodenal stump leak/blow out Nutritional deficiencies - Iron deficiency anemia (most common), Vit B 12 deficiency, and osteoporosis Bile reflux gastritis and esophagitis Gallstones</li><li>➤ Dumping syndrome ( early and late)</li><li>➤ Dumping syndrome (</li><li>➤ Diarrhea</li><li>➤ Duodenal stump leak/blow out</li><li>➤ Nutritional deficiencies - Iron deficiency anemia (most common), Vit B 12 deficiency, and osteoporosis</li><li>➤ Nutritional deficiencies -</li><li>➤ Bile reflux gastritis and esophagitis</li><li>➤ Gallstones</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the incorrect statement about anatomy of stomach?", "options": [{"label": "A", "text": "Incisura is the narrowest part of the stomach tube", "correct": false}, {"label": "B", "text": "Short gastric arteries arise from splenic artery", "correct": false}, {"label": "C", "text": "G-E junction is surgically identified by Belsey’s fat pad", "correct": false}, {"label": "D", "text": "Criminal nerve of Grassi arises from both anterior and posterior Vagus", "correct": true}], "correct_answer": "D. Criminal nerve of Grassi arises from both anterior and posterior Vagus", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/15/picture2_VwQVZYM.jpg"], "explanation": "<p><strong>Ans. D) Criminal nerve of Grassi arises from both anterior and posterior Vagus</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Incisura is the narrowest part of the stomach tube . True . The angular incisura, also known as the angular notch , is located along the lesser curvature of the stomach and is often the narrowest part of the stomach tube .</li><li>• Option A: Incisura is the narrowest part of the stomach tube</li><li>• True</li><li>• angular notch</li><li>• located along the lesser curvature of the stomach</li><li>• narrowest part of the stomach tube</li><li>• Option B: Short gastric arteries arise from splenic artery . True . The short gastric arteries , which supply the fundus of the stomach , indeed arise from the splenic artery .</li><li>• Option B: Short gastric arteries arise from splenic artery</li><li>• True</li><li>• short gastric arteries</li><li>• fundus of the stomach</li><li>• splenic artery</li><li>• Option C: G-E junction is surgically identified by fat pad . True . Surgically, the gastroesophageal (G-E) junction can be identified by the Belsey fat pad , which is a pad of fat near this junction.</li><li>• Option C: G-E junction is surgically identified by fat pad</li><li>• True</li><li>• gastroesophageal</li><li>• junction</li><li>• Belsey fat pad</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The \"criminal nerve of Grassi\" arises from the posterior vagus nerve and is a critical consideration during a highly selective vagotomy to prevent the recurrence of peptic ulcers .</li><li>➤ \"criminal nerve of Grassi\"</li><li>➤ posterior vagus nerve</li><li>➤ highly selective vagotomy to prevent the recurrence of peptic ulcers</li><li>➤ Blood supply: Left Gastric Artery (Celiac trunk) and Right Gastric Artery (CHA) along lesser curve.</li><li>➤ Blood supply:</li><li>➤ Left Gastric Artery</li><li>➤ Right Gastric Artery</li><li>➤ lesser curve.</li><li>➤ Left Gastro-epiploic (LGE) and short gastric from Splenic artery ; and RGE (from GDA) along greater curve</li><li>➤ Left Gastro-epiploic</li><li>➤ short gastric from Splenic artery</li><li>➤ RGE</li><li>➤ greater curve</li><li>➤ GE junction is identified by Belsey fat pad during surgery and squamo-columnar junction during endoscopy.</li><li>➤ GE junction</li><li>➤ Belsey fat pad during surgery</li><li>➤ squamo-columnar junction</li><li>➤ Ref : Bailey 28 th Ed pg 1148.</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed pg 1148.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "The most common site of gastric ulcer is?", "options": [{"label": "A", "text": "Lesser curvature near incisura", "correct": true}, {"label": "B", "text": "Greater curvature", "correct": false}, {"label": "C", "text": "Body", "correct": false}, {"label": "D", "text": "Prepyloric", "correct": false}], "correct_answer": "A. Lesser curvature near incisura", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Lesser curvature near incisura</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Greater curvature . False . Gastric ulcers less commonly occur along the greater curvature of the stomach. This area has better blood supply and more robust protective mechanisms against gastric acid.</li><li>• Option B: Greater curvature</li><li>• False</li><li>• less commonly occur</li><li>• greater curvature of the stomach.</li><li>• better blood supply</li><li>• robust protective mechanisms</li><li>• Option C: Body . False . While ulcers can occur in the body of the stomach , they are less common compared to the lesser curvature near the incisura .</li><li>• Option C: Body</li><li>• False</li><li>• ulcers</li><li>• occur in the body of the stomach</li><li>• less common</li><li>• lesser curvature near the incisura</li><li>• Option D: Prepyloric . False . Prepyloric ulcers are those found in the antral region of the stomach , close to the pyloric sphincter . They are less common than ulcers on the lesser curvature near the incisura.</li><li>• Option D: Prepyloric</li><li>• False</li><li>• found in the antral region of the stomach</li><li>• pyloric sphincter</li><li>• less common</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most common site for gastric ulcers is the lesser curvature of the stomach , near the angular incisura . These ulcers are often associated with low to normal acid output and are classified as type I gastric ulcers.</li><li>➤ most common site for gastric ulcers</li><li>➤ lesser curvature of the stomach</li><li>➤ angular incisura</li><li>➤ The most common site of gastric ulcer is the lesser curvature near incisura. Approximately 60% of ulcers are in this location and are classified as type I gastric ulcers. These ulcers are generally not associated with excessive acid secretion and may occur with low to normal acid output.</li><li>➤ The most common site of gastric ulcer is the lesser curvature near incisura.</li><li>➤ Approximately 60% of ulcers are in this location and are classified as type I gastric ulcers.</li><li>➤ These ulcers are generally not associated with excessive acid secretion and may occur with low to normal acid output.</li><li>➤ may occur with low to normal acid output.</li><li>➤ Ref : Bailey and Love 28 th edition pg 1154</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th edition pg 1154</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient presents with gnawing epigastric pain after meals. On upper GI endoscopy followed by the urease test, rapid urease activity was detected at the antrum. Which type of gastritis is associated with the above organism?", "options": [{"label": "A", "text": "Autoimmune Type A gastritis", "correct": false}, {"label": "B", "text": "H. Pylori associated Туре В gastritis", "correct": true}, {"label": "C", "text": "Reflux gastritis", "correct": false}, {"label": "D", "text": "Erosive gastritis", "correct": false}], "correct_answer": "B. H. Pylori associated Туре В gastritis", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) H. Pylori associated Type B gastritis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Type A gastritis . Type A gastritis, or autoimmune gastritis , is characterized by autoantibodies against gastric parietal cells and intrinsic factor , leading to atrophy of the stomach lining , achlorhydria, and potential development of pernicious anemia due to vitamin B12 malabsorption.</li><li>• Option A: Type A gastritis</li><li>• autoimmune gastritis</li><li>• autoantibodies against gastric parietal cells and intrinsic factor</li><li>• atrophy of the stomach lining</li><li>• achlorhydria,</li><li>• Option C: Reflux gastritis . Reflux gastritis is a type of gastritis resulting from the reflux of bile acids into the stomach , typically after surgery involving the stomach like gastro-jejunostomy . It is not associated with Helicobacter pylori.</li><li>• Option C: Reflux gastritis</li><li>• type of gastritis</li><li>• reflux of bile acids into the stomach</li><li>• after surgery</li><li>• stomach like gastro-jejunostomy</li><li>• Option D: Erosive gastritis . Erosive gastritis involves the erosion of the gastric mucosa due to various causes such as medications (like NSAIDs), alcohol, or stress . It is also not directly related to Helicobacter pylori infection.</li><li>• Option D: Erosive gastritis</li><li>• erosion of the gastric mucosa</li><li>• causes such as medications</li><li>• alcohol, or stress</li><li>• The correct answer is Option B: Type B gastritis , which is associated with Helicobacter pylori infection that commonly affects the antrum of the stomach.</li><li>• Option B: Type B gastritis</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Type B gastritis is associated with Helicobacter pylori infection and commonly presents with antral involvement , which can be detected by a rapid urease test during endoscopy .</li><li>➤ Type B gastritis</li><li>➤ Helicobacter pylori infection</li><li>➤ presents with antral involvement</li><li>➤ detected by a rapid urease test during endoscopy</li><li>➤ Type B gastritis</li><li>➤ Type B gastritis</li><li>➤ Type B gastritis is associated with H. pylori. It commonly affects the antrum. Intestinal metaplasia is associated with chronic pan-gastritis with atrophy . Intestinal metaplasia with dysplasia has malignant potential.</li><li>➤ Type B gastritis is associated with H. pylori.</li><li>➤ Type B gastritis is associated with H. pylori.</li><li>➤ It commonly affects the antrum.</li><li>➤ It commonly affects the antrum.</li><li>➤ commonly affects the antrum.</li><li>➤ Intestinal metaplasia is associated with chronic pan-gastritis with atrophy .</li><li>➤ Intestinal metaplasia is associated with chronic pan-gastritis with atrophy .</li><li>➤ chronic pan-gastritis with atrophy</li><li>➤ Intestinal metaplasia with dysplasia has malignant potential.</li><li>➤ Intestinal metaplasia with dysplasia has malignant potential.</li><li>➤ Type A gastritis</li><li>➤ Type A gastritis</li><li>➤ Autoimmune condition : Has circulating antibodies to parietal cells Atrophy of parietal cell mass Achlorhydria: causes chronic hypergastrinemia and microadenomas of enterochromaffin-like (ECL) cells Anemia: leads to pernicious anemia , due to malabsorption of Vit B12 (as intrinsic factor is also produced by parietal cells)</li><li>➤ Autoimmune condition : Has circulating antibodies to parietal cells</li><li>➤ Autoimmune condition : Has circulating antibodies to parietal cells</li><li>➤ Autoimmune condition</li><li>➤ Atrophy of parietal cell mass</li><li>➤ Atrophy of parietal cell mass</li><li>➤ Atrophy of parietal cell mass</li><li>➤ Achlorhydria: causes chronic hypergastrinemia and microadenomas of enterochromaffin-like (ECL) cells</li><li>➤ Achlorhydria: causes chronic hypergastrinemia and microadenomas of enterochromaffin-like (ECL) cells</li><li>➤ Achlorhydria:</li><li>➤ Anemia: leads to pernicious anemia , due to malabsorption of Vit B12 (as intrinsic factor is also produced by parietal cells)</li><li>➤ Anemia: leads to pernicious anemia , due to malabsorption of Vit B12 (as intrinsic factor is also produced by parietal cells)</li><li>➤ Anemia: leads to pernicious anemia</li><li>➤ Ref : Bailey and Love edition 28, page 1155</li><li>➤ Ref : Bailey and Love edition 28, page 1155</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "What sample is required to diagnose the organism shown in this test slide?", "options": [{"label": "A", "text": "Serum", "correct": false}, {"label": "B", "text": "Breath", "correct": false}, {"label": "C", "text": "Stools", "correct": false}, {"label": "D", "text": "Gastric mucosa", "correct": true}], "correct_answer": "D. Gastric mucosa", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/02/untitled-177.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. D) Gastric mucosa</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Serum . False. Serum is not used in the rapid urease test . While serum can be used for serological testing to detect antibodies against H. pylori, it does not directly test for the presence of the organism.</li><li>• Option A: Serum</li><li>• Serum is not used in the rapid urease test</li><li>• Option B: Breath . False. Breath tests are used for diagnosing H. pylori infection, but they work differently from the rapid urease test . They typically involve the patient ingesting a urea compound labeled with a carbon isotope, and exhaled breath is then analyzed for the presence of the isotope, which indicates urease activity.</li><li>• Option B: Breath</li><li>• Breath tests are used for diagnosing H. pylori infection, but they work differently from the rapid urease test</li><li>• Option C: Stools . False. Stool antigen tests can be used to diagnose H. pylori infection , but they are not related to the rapid urease test shown in the slide.</li><li>• Option C: Stools</li><li>• Stool antigen tests can be used to diagnose H. pylori infection</li><li>• not related to the rapid urease test</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The rapid urease test is used to diagnose H. pylori infection using a gastric mucosa biopsy sample . The test detects urease, an enzyme produced by H. pylori , which hydrolyzes urea to produce ammonia , leading to an alkaline pH change that is indicated by a color change on the test slide</li><li>➤ rapid urease test is used to diagnose H. pylori infection</li><li>➤ gastric mucosa biopsy sample</li><li>➤ detects urease, an enzyme produced by H. pylori</li><li>➤ hydrolyzes urea to produce ammonia</li><li>➤ This is a rapid urease test done for diagnosis of H. Pylori gastritis from antral mucosal biopsy. One of the characteristics of H. pylori is its ability to hydrolyse urea , resulting in the production of ammonia, a strong alkali. The effect of ammonia on the antral G cells is to cause release of gastrin via negative feedback that is responsible for the modest, but inappropriate, hypergastrinemia in patients with peptic ulcer disease which, in turn, may result in gastric acid hypersecretion. The organism’s obligate urease activity is utilized by various tests used to detect the presence of the organism, including the 13C and 14C breath tests and the CLO test (a commercially available urease test kit), which is performed on gastric biopsies. The organism can also be detected histologically using the Giemsa or the Warthin–Starry silver stains , and cultured using appropriate media. Previous or current infection with the organism may also be detected serologically. Breath tests or fecal antigen tests are recommended for the pretreatment diagnosis of H. pylori infection in the community. Less accurate, hospital-based serology tests have a place within a non-invasive test-and-treat strategy.</li><li>➤ This is a rapid urease test done for diagnosis of H. Pylori gastritis from antral mucosal biopsy.</li><li>➤ One of the characteristics of H. pylori is its ability to hydrolyse urea , resulting in the production of ammonia, a strong alkali. The effect of ammonia on the antral G cells is to cause release of gastrin via negative feedback that is responsible for the modest, but inappropriate, hypergastrinemia in patients with peptic ulcer disease which, in turn, may result in gastric acid hypersecretion.</li><li>➤ hydrolyse urea</li><li>➤ release of gastrin via negative feedback that is responsible for the modest, but inappropriate, hypergastrinemia</li><li>➤ The organism’s obligate urease activity is utilized by various tests used to detect the presence of the organism, including the 13C and 14C breath tests and the CLO test (a commercially available urease test kit), which is performed on gastric biopsies.</li><li>➤ The organism can also be detected histologically using the Giemsa or the Warthin–Starry silver stains , and cultured using appropriate media. Previous or current infection with the organism may also be detected serologically.</li><li>➤ Giemsa or the Warthin–Starry silver stains</li><li>➤ Breath tests or fecal antigen tests are recommended for the pretreatment diagnosis of H. pylori infection in the community. Less accurate, hospital-based serology tests have a place within a non-invasive test-and-treat strategy.</li><li>➤ Breath tests or fecal antigen tests</li><li>➤ Ref : Bailey 28 th Edition, page 1155.</li><li>➤ Ref</li><li>➤ : Bailey 28 th Edition, page 1155.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of these pathologies occur due to H. Pylori infection of stomach except?", "options": [{"label": "A", "text": "Chronic gastritis", "correct": false}, {"label": "B", "text": "Duodenal ulcer", "correct": false}, {"label": "C", "text": "Adenocarcinoma of stomach", "correct": false}, {"label": "D", "text": "Duodenal adenocarcinoma", "correct": true}], "correct_answer": "D. Duodenal adenocarcinoma", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Duodenal adenocarcinoma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Chronic gastritis . True. H. pylori is a well-established cause of chronic gastritis . The bacteria's presence disrupts the gastric mucosal barrier and induces inflammation.</li><li>• Option A: Chronic gastritis</li><li>• H. pylori is a well-established cause of chronic gastritis</li><li>• Option B: Duodenal ulcer . True. H. pylori infection is a major cause of duodenal ulcers . The bacteria increase gastric acid secretion and decrease bicarbonate production, leading to ulcers in the duodenum.</li><li>• Option B: Duodenal ulcer</li><li>• H. pylori infection is a major cause of duodenal ulcers</li><li>• Option C: Adenocarcinoma of the stomach . True. Chronic infection with H. pylori, especially strains producing cytotoxins like CagA and VacA , is associated with an increased risk of gastric adenocarcinoma .</li><li>• Option C: Adenocarcinoma of the stomach</li><li>• Chronic infection with H. pylori, especially strains producing cytotoxins like CagA and VacA</li><li>• increased risk of gastric adenocarcinoma</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Understanding the diseases associated with H. pylori infection is crucial for proper diagnosis and treatment. Chronic gastritis, peptic ulcers, and gastric adenocarcinoma are all conditions linked to this infection, but duodenal adenocarcinoma is not.</li><li>➤ Chronic gastritis, peptic ulcers, and gastric adenocarcinoma</li><li>➤ Infection with H. pylori leads to disruption of the gastric mucosal barrier by the enzymes produced by the organism, and the inflammation induced in the gastric epithelium is the basis of many of the associated disease processes. The association of the organism with chronic (type B) gastritis is not in doubt. Some strains of H. pylori produce cytotoxins, notably the Cag A and Vac A products. Production of cytotoxins seems to be associated with the ability to cause gastritis, peptic ulceration and gastric cancer.</li><li>➤ Infection with H. pylori leads to disruption of the gastric mucosal barrier by the enzymes produced by the organism, and the inflammation induced in the gastric epithelium is the basis of many of the associated disease processes.</li><li>➤ The association of the organism with chronic (type B) gastritis is not in doubt.</li><li>➤ Some strains of H. pylori produce cytotoxins, notably the Cag A and Vac A products.</li><li>➤ Cag A and Vac A</li><li>➤ Production of cytotoxins seems to be associated with the ability to cause gastritis, peptic ulceration and gastric cancer.</li><li>➤ Production of cytotoxins seems to be associated with the ability to cause gastritis, peptic ulceration and gastric cancer.</li><li>➤ Ref : Bailey 28 th Edition, page 1155.</li><li>➤ Ref</li><li>➤ : Bailey 28 th Edition, page 1155.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 40-year-old man has a history of severe epigastric pain and the pain was relieved after meals. Since treatment with PPIs turned out to be unsatisfactory, the following surgical procedure “C” was done. What is false regarding the procedure depicted here?", "options": [{"label": "A", "text": "The Crow’s feet are spared distally", "correct": false}, {"label": "B", "text": "Has a relatively higher ulcer recurrence rate", "correct": false}, {"label": "C", "text": "Has the lowest post-operative mortality", "correct": false}, {"label": "D", "text": "A pyloroplasty is usually required for drainage", "correct": true}], "correct_answer": "D. A pyloroplasty is usually required for drainage", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/02/untitled-178.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. D) A pyloroplasty is usually required for drainage</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: The Crow's feet are spared distally True. In HSV, the individual seromuscular branches of the anterior and posterior vagus nerves are divided , preserving the main trunks and the last 6-7 cm of the pyloric branches known as Crow's feet . This spares the pylorus and obviates the need for a drainage procedure.</li><li>• Option A: The Crow's feet are spared distally</li><li>• seromuscular branches of the anterior and posterior vagus nerves are divided</li><li>• main trunks and the last 6-7 cm of the pyloric branches known as Crow's feet</li><li>• Option B: Has a relatively higher ulcer recurrence rate True. Although HSV reduces the risk of ulcer recurrence compared to other surgical treatments , there is still a reported recurrence rate of 2-10%.</li><li>• Option B: Has a relatively higher ulcer recurrence rate</li><li>• HSV reduces the risk of ulcer recurrence</li><li>• surgical treatments</li><li>• Option C: Has the lowest post-operative mortality True. HSV is associated with a low postoperative complication rate and has one of the lowest mortality rates among surgical procedures for peptic ulcer disease, at around 0.2%.</li><li>• Option C: Has the lowest post-operative mortality</li><li>• low postoperative complication rate and has one of the lowest mortality rates</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Highly selective vagotomy is a surgical procedure performed to treat peptic ulcer disease by selectively severing branches of the vagus nerve that innervate the acid-producing part of the stomach , sparing the pylorus and avoiding the need for additional drainage procedures like pyloroplasty . This procedure is characterized by a reduction of acid output, preservation of the Crow's feet, a moderate ulcer recurrence rate, and a low rate of postoperative complications and mortality, making it a well-tolerated treatment option.</li><li>➤ Highly selective vagotomy</li><li>➤ surgical procedure performed to treat peptic ulcer disease by selectively severing branches of the vagus nerve</li><li>➤ innervate the acid-producing part of the stomach</li><li>➤ sparing the pylorus</li><li>➤ avoiding the need</li><li>➤ pyloroplasty</li><li>➤ HSV:</li><li>➤ HSV:</li><li>➤ Individual branches of anterior and post Vagus are divided , preserving the main trunks as well as the last 6-7 cm of pyloric branches (Crow’s feet) As pylorus is spared, a drainage procedure like pyloroplasty is not needed . Acid reduction is moderate High ulcer recurrence rate (2-10%) Minimum postoperative complications (&lt;5%) and lowest mortality (0.2%) It is a BEST TOLERATED vagotomy procedure due to limited side effects</li><li>➤ Individual branches of anterior and post Vagus are divided , preserving the main trunks as well as the last 6-7 cm of pyloric branches (Crow’s feet)</li><li>➤ Individual branches of anterior and post Vagus are divided</li><li>➤ (Crow’s feet)</li><li>➤ As pylorus is spared, a drainage procedure like pyloroplasty is not needed .</li><li>➤ pyloroplasty is not needed</li><li>➤ Acid reduction is moderate</li><li>➤ Acid reduction is moderate</li><li>➤ High ulcer recurrence rate (2-10%)</li><li>➤ High ulcer recurrence rate (2-10%)</li><li>➤ Minimum postoperative complications (&lt;5%) and lowest mortality (0.2%)</li><li>➤ It is a BEST TOLERATED vagotomy procedure due to limited side effects</li><li>➤ BEST TOLERATED vagotomy</li><li>➤ Other points regarding vagotomy:</li><li>➤ Other points regarding vagotomy:</li><li>➤ Truncal vagotomy (cutting the vagal nerves at the lower esophagus) was the mainstay of treatment of duodenal ulceration Because the vagal nerves are motor to the stomach, denervation of the antro-pyloro-duodenal segment results in gastric stasis in a substantial proportion of patients on whom truncal vagotomy alone is performed. The most popular drainage procedure was the Heineke-Mikulicz pyloroplasty . Gastrojejunostomy is an alternative drainage procedure to pyloroplasty. In highly selective vagotomy, only the parietal cell mass of the stomach is denervated .</li><li>➤ Truncal vagotomy (cutting the vagal nerves at the lower esophagus) was the mainstay of treatment of duodenal ulceration</li><li>➤ Because the vagal nerves are motor to the stomach, denervation of the antro-pyloro-duodenal segment results in gastric stasis in a substantial proportion of patients on whom truncal vagotomy alone is performed. The most popular drainage procedure was the Heineke-Mikulicz pyloroplasty .</li><li>➤ Heineke-Mikulicz pyloroplasty</li><li>➤ Gastrojejunostomy is an alternative drainage procedure to pyloroplasty.</li><li>➤ In highly selective vagotomy, only the parietal cell mass of the stomach is denervated .</li><li>➤ In highly selective vagotomy, only the parietal cell mass of the stomach is denervated</li><li>➤ Ref : Bailey 28 th Ed. Fig 67.19, Page 1161</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Fig 67.19, Page 1161</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Two months following Billroth 2 reconstruction done for peptic ulcer disease, patient complaints of lightheadedness, bloating and diarrhea 15 minutes after certain meals. He is suffering from?", "options": [{"label": "A", "text": "Early dumping", "correct": true}, {"label": "B", "text": "Late dumping", "correct": false}, {"label": "C", "text": "Post vagotomy diarrhea", "correct": false}, {"label": "D", "text": "G-J ulceration", "correct": false}], "correct_answer": "A. Early dumping", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/15/screenshot-2024-03-15-192203.jpg"], "explanation": "<p><strong>Ans. A) Early dumping</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Late dumping. Happens 1 to 3 hours after eating and is associated with hypoglycemia due to an exaggerated insulin response . Symptoms include weakness, sweating, and palpitations. It does not match the immediate post-meal timeframe mentioned.</li><li>• Option B: Late dumping.</li><li>• 1 to 3 hours after eating</li><li>• associated with hypoglycemia</li><li>• exaggerated insulin response</li><li>• Option C: Post vagotomy diarrhea This can occur after gastric surgery due to altered motility but typically does not cause lightheadedness or is related to meal timing.</li><li>• Option C: Post vagotomy diarrhea</li><li>• occur after gastric surgery</li><li>• altered motility</li><li>• does not cause lightheadedness</li><li>• Option D: G-J ulceration Gastrojejunal ulceration can cause symptoms like pain, but it is less likely to cause immediate postprandial symptoms like lightheadedness or diarrhea unless there is significant bleeding or obstruction , which is not described here.</li><li>• Option D: G-J ulceration</li><li>• symptoms like pain, but it is less likely to cause immediate postprandial symptoms like lightheadedness or diarrhea</li><li>• significant bleeding or obstruction</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Early dumping syndrome is a complication that can occur after gastric surgery , such as a Billroth II reconstruction , and is characterized by symptoms of lightheadedness, tachycardia, diaphoresis, and diarrhea shortly after eating . These symptoms are due to the rapid transit of food into the small intestine, causing fluid shifts and autonomic reactions.</li><li>➤ Early dumping syndrome</li><li>➤ occur after gastric surgery</li><li>➤ Billroth II reconstruction</li><li>➤ symptoms of lightheadedness, tachycardia, diaphoresis, and diarrhea</li><li>➤ after eating</li><li>➤ Ref : Bailey 28 th Ed. Table 67.3</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Table 67.3</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "According to modified Johnson’s classification, hyperacid secretion is seen in which type of gastric ulcer?", "options": [{"label": "A", "text": "1", "correct": false}, {"label": "B", "text": "2", "correct": true}, {"label": "C", "text": "4", "correct": false}, {"label": "D", "text": "5", "correct": false}], "correct_answer": "B. 2", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/15/screenshot-2024-03-15-193147.jpg"], "explanation": "<p><strong>Ans. B) 2</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Modified Johnson’s classification for location of peptic ulcers :</li><li>• Modified Johnson’s classification</li><li>• peptic ulcers</li><li>• Type I - True gastric ulcers (lesser curve)</li><li>• Type I</li><li>• Type II - Combined gastric and duodenal ulcers - Hyperacid secretion</li><li>• Type II</li><li>• Hyperacid secretion</li><li>• Type III - Supra-pyloric and pyloric ulcers - Hyperacid secretion</li><li>• Type III</li><li>• Hyperacid secretion</li><li>• Type IV - Proximal ulcers (GE junction)</li><li>• Type IV</li><li>• Type V - NSAID induced</li><li>• Type V</li><li>• Ref : Sabiston 21 st Ed. Pg 1207.</li><li>• Ref</li><li>• : Sabiston 21 st Ed. Pg 1207.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "What is the incorrect statement about this device?", "options": [{"label": "A", "text": "Allows visualization up to second part of duodenum (D2)", "correct": false}, {"label": "B", "text": "Can be used for variceal banding", "correct": false}, {"label": "C", "text": "Gold standard investigation for stomach disorders", "correct": false}, {"label": "D", "text": "Useful for diagnosing GIST", "correct": true}], "correct_answer": "D. Useful for diagnosing GIST", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/02/untitled-180.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. D) Useful for diagnosing GIST</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Allows visualization up to D2 This statement is true . An upper GI endoscope allows visualization of the esophagus, stomach, and proximal duodenum up to the second part (D2).</li><li>• Option A: Allows visualization up to D2</li><li>• true</li><li>• Option B: Can be used for variceal banding This is correct . The endoscope can be used to perform variceal banding, which is a treatment for esophageal varices.</li><li>• Option B: Can be used for variceal banding</li><li>• correct</li><li>• Option C: Gold standard investigation for stomach. Endoscopy is indeed considered the gold standard for diagnosing many stomach conditions , such as peptic ulcers and gastritis.</li><li>• Option C: Gold standard investigation for stomach.</li><li>• Endoscopy</li><li>• gold standard for diagnosing many stomach conditions</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ An upper GI endoscope is a versatile tool that allows visualization and intervention in the esophagus, stomach, and proximal duodenum . It is the gold standard for diagnosing mucosal diseases of the upper gastrointestinal tract and enables therapeutic procedures like variceal banding . However, it may not be sufficient for diagnosing submucosal lesions like GISTs, where additional imaging modalities may be required.</li><li>➤ upper GI endoscope</li><li>➤ versatile tool that allows visualization and intervention in the esophagus, stomach, and proximal duodenum</li><li>➤ gold standard</li><li>➤ diagnosing mucosal diseases of the upper gastrointestinal tract and enables therapeutic procedures</li><li>➤ variceal banding</li><li>➤ Ref : Bailey 28 th Ed. Pg 1152.</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 1152.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old male patient after undergoing surgery for peptic ulcer complains of light headedness after eating bread or rice. He has had episodes of fainting. All of these are useful in the management of his condition except?", "options": [{"label": "A", "text": "Avoid high glycemic index foods", "correct": false}, {"label": "B", "text": "Have lesser but larger meals per day", "correct": true}, {"label": "C", "text": "Octreotide", "correct": false}, {"label": "D", "text": "Reverse the surgery", "correct": false}], "correct_answer": "B. Have lesser but larger meals per day", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Have lesser meals per day</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Avoid high glycemic index foods: This option is useful in the management of the dumping . High glycemic index foods can cause rapid spikes in blood sugar levels , which may exacerbate symptoms of postprandial hypoglycemia , leading to lightheadedness and fainting episodes . Therefore, avoiding high glycemic index foods can help stabilize blood sugar levels and alleviate symptoms.</li><li>• Option</li><li>• A. Avoid high glycemic index foods:</li><li>• useful in the management of the dumping</li><li>• High glycemic index foods</li><li>• rapid spikes in blood sugar levels</li><li>• exacerbate symptoms of postprandial hypoglycemia</li><li>• lightheadedness and fainting episodes</li><li>• Option C. Octreotide: This option is useful in the management of the patient's condition . Octreotide, a synthetic analog of somatostatin, can help control symptoms of postprandial hypoglycemia by inhibiting the release of insulin and other hormones that contribute to hypoglycemia.</li><li>• Option</li><li>• C. Octreotide:</li><li>• management of the patient's condition</li><li>• Octreotide, a synthetic analog of somatostatin,</li><li>• control symptoms of postprandial hypoglycemia</li><li>• Option D. Reverse the surgery: This option is the last resort in the management of the patient's condition .</li><li>• Option</li><li>• D. Reverse the surgery:</li><li>• last resort in the management of the patient's condition</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Understanding the management strategies for postprandial dumping involves the role of dietary modifications, medications such as octreotide , and lifestyle changes.</li><li>➤ management strategies for postprandial dumping</li><li>➤ role of dietary modifications, medications such as octreotide</li><li>➤ The principal treatment is dietary manipulation. Small, regular meals based on fat and protein are best. Avoiding fluids with a high carbohydrate content also helps. The somatostatin analogue octreotide given before meals is useful in some individuals and the long-acting preparation may also be useful. Revisional surgery may be occasionally required. In patients with a gastroenterostomy, the drainage may be taken down.</li><li>➤ The principal treatment is dietary manipulation. Small, regular meals based on fat and protein are best. Avoiding fluids with a high carbohydrate content also helps.</li><li>➤ The somatostatin analogue octreotide given before meals is useful in some individuals and the long-acting preparation may also be useful.</li><li>➤ Revisional surgery may be occasionally required. In patients with a gastroenterostomy, the drainage may be taken down.</li><li>➤ Ref : Bailey 28 th Ed. Pg. 1163.</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg. 1163.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In peptic ulcer disease (PUD), which of the following statements is incorrect regarding its complications?", "options": [{"label": "A", "text": "The most common complication of peptic ulcer disease is bleeding, followed by perforation and obstruction", "correct": false}, {"label": "B", "text": "Fever is a late feature of peptic perforation", "correct": false}, {"label": "C", "text": "The most common vessel responsible for bleeding in peptic ulcer disease is the splenic artery", "correct": true}, {"label": "D", "text": "The most common site for perforation of peptic ulcer is the first part of the duodenum.", "correct": false}], "correct_answer": "C. The most common vessel responsible for bleeding in peptic ulcer disease is the splenic artery", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) The most common vessel responsible for bleeding in peptic ulcer disease is the splenic artery</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: This statement is correct . Bleeding is indeed the most common complication of PUD, and perforation and obstruction are also well-recognized complications.</li><li>• Option A:</li><li>• correct</li><li>• Option B: Fever as a late feature of perforation is also correct . Initially, patients with perforated ulcers may not exhibit fever; the inflammatory response leading to fever may take some time to develop.</li><li>• Option B:</li><li>• correct</li><li>• Option D: The location of the most common site for perforation in PUD is correct ; the anterior wall of the first part of the duodenum is the most likely site of perforation.</li><li>• Option D:</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The gastroduodenal artery , not the splenic artery , is most commonly implicated in bleeding related to peptic ulcer disease .</li><li>➤ gastroduodenal artery</li><li>➤ splenic artery</li><li>➤ most commonly implicated in bleeding related to peptic ulcer disease</li><li>➤ Clinical features:</li><li>➤ Clinical features:</li><li>➤ The patient, who may have a history of peptic ulceration, develops sudden-onset severe generalised abdominal pain. The abdomen exhibits a board-like rigidity , and the patient is disinclined to move because of the pain. The abdomen does not move with respiration. Fever due to bacterial peritonitis is a late feature. An erect chest radiograph will reveal free gas under the diaphragm in more than 50% of cases with perforated peptic ulcer but CT imaging is now most commonly used and is more accurate. The initial priorities are resuscitation and analgesia. A thorough peritoneal toilet to remove all of the fluid and food debris. If the perforation is in the duodenum, it can usually be closed by several well-placed sutures, closing the ulcer in a transverse direction. It is common to place an omental patch (Graham’s repair) over the perforation in the hope of enhancing the chances of the leak sealing.</li><li>➤ The patient, who may have a history of peptic ulceration, develops sudden-onset severe generalised abdominal pain.</li><li>➤ The abdomen exhibits a board-like rigidity , and the patient is disinclined to move because of the pain. The abdomen does not move with respiration. Fever due to bacterial peritonitis is a late feature.</li><li>➤ board-like rigidity</li><li>➤ Fever due to bacterial peritonitis is a late feature.</li><li>➤ An erect chest radiograph will reveal free gas under the diaphragm in more than 50% of cases with perforated peptic ulcer but CT imaging is now most commonly used and is more accurate.</li><li>➤ free gas under the diaphragm</li><li>➤ The initial priorities are resuscitation and analgesia.</li><li>➤ A thorough peritoneal toilet to remove all of the fluid and food debris. If the perforation is in the duodenum, it can usually be closed by several well-placed sutures, closing the ulcer in a transverse direction.</li><li>➤ It is common to place an omental patch (Graham’s repair) over the perforation in the hope of enhancing the chances of the leak sealing.</li><li>➤ omental patch</li><li>➤ (Graham’s repair)</li><li>➤ Ref : Bailey 28 th Ed. Pg 1164-65</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 1164-65</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient present with multiple episodes of vomiting of blood. What is its most common cause?", "options": [{"label": "A", "text": "Esophageal varices", "correct": false}, {"label": "B", "text": "Peptic ulcer", "correct": true}, {"label": "C", "text": "Gastritis", "correct": false}, {"label": "D", "text": "Mallory-Weiss syndrome", "correct": false}], "correct_answer": "B. Peptic ulcer", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/22/screenshot-2024-03-22-185138.png"], "explanation": "<p><strong>Ans. B) Peptic ulcer</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A : While esophageal varices can lead to severe episodes of hematemesis , especially in the context of portal hypertension , they are not the most common cause overall.</li><li>• Option A</li><li>• esophageal varices</li><li>• severe episodes of hematemesis</li><li>• portal hypertension</li><li>• Option C: Gastritis can rarely cause hematemesis.</li><li>• Option C:</li><li>• Gastritis</li><li>• rarely cause hematemesis.</li><li>• Option D: A Mallory-Weiss tear can result in hematemesis after an episode of forceful vomiting , but it is less common compared to peptic ulcers.</li><li>• Option D:</li><li>• Mallory-Weiss tear</li><li>• hematemesis after an episode of forceful vomiting</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Peptic ulcers are the leading cause of upper gastrointestinal bleeding and can present with hematemesis . Managing peptic ulcer disease effectively can help prevent this serious complication.</li><li>➤ Peptic ulcers</li><li>➤ cause of upper gastrointestinal bleeding</li><li>➤ present with hematemesis</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1166</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th Ed. Pg 1166</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 30-year-old male, who has a history of chronic NSAID usage presents with hematemesis and abdominal pain. On endoscopy an actively bleeding peptic ulcer was seen which was around 1.5cm in size. The ulcer was located on the posterior wall of the duodenum. What is the next best step in management?", "options": [{"label": "A", "text": "PPIs with regular follow up", "correct": false}, {"label": "B", "text": "Injection Adrenaline with clips", "correct": true}, {"label": "C", "text": "Duodenotomy and repair", "correct": false}, {"label": "D", "text": "Grahams omental patch repair", "correct": false}], "correct_answer": "B. Injection Adrenaline with clips", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Inj. Adrenaline with clips</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A : While H2 antagonists or PPIs are important in the medical management of peptic ulcers , in the setting of active bleeding , immediate endoscopic intervention is required before m.</li><li>• Option A</li><li>• H2 antagonists or PPIs</li><li>• medical management of peptic ulcers</li><li>• setting of active bleeding</li><li>• Option C: Duodenotomy and repair , an open surgical procedure , is typically reserved for cases where endoscopic treatment has failed or is not feasible.</li><li>• Option C:</li><li>• Duodenotomy and repair</li><li>• open surgical procedure</li><li>• endoscopic treatment has failed</li><li>• Option D: Graham’s omental patch repair is used in duodenal perforation .</li><li>• Option D:</li><li>• Graham’s omental patch repair</li><li>• duodenal perforation</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In the case of an actively bleeding peptic ulcer , the initial management should be endoscopic therapy , which includes the injection of adrenaline and the application of clips to control the hemorrhage. This dual endotherapy is effective in achieving hemostasis in a significant proportion of cases. Surgery is considered when endoscopic treatment fails after repeated attempts.</li><li>➤ actively bleeding peptic ulcer</li><li>➤ initial management should be endoscopic therapy</li><li>➤ injection of adrenaline and the application of clips to control the hemorrhage.</li><li>➤ dual endotherapy</li><li>➤ hemostasis</li><li>➤ In this case, endoscopic injection of adrenaline + clips (dual endotherapy) is the next step. Therapeutic endoscopy can achieve hemostasis in approximately 70% of cases, with the best evidence supporting a combination of adrenaline injection with heater probe and/or clips. In patients where the source of bleeding cannot be identified or in those who rebleed after endoscopy, angiography with transcatheter embolization may offer a valuable alternative. Surgery is only done when 2 attempts of endoscopic therapy fail. Surgical management includes duodenotomy and under-running of the vessel. Duodenal ulcers also show good response to vagotomy/ acid reduction surgeries.</li><li>➤ In this case, endoscopic injection of adrenaline + clips (dual endotherapy) is the next step.</li><li>➤ injection of adrenaline + clips (dual endotherapy)</li><li>➤ Therapeutic endoscopy can achieve hemostasis in approximately 70% of cases, with the best evidence supporting a combination of adrenaline injection with heater probe and/or clips. In patients where the source of bleeding cannot be identified or in those who rebleed after endoscopy, angiography with transcatheter embolization may offer a valuable alternative.</li><li>➤ combination</li><li>➤ Surgery is only done when 2 attempts of endoscopic therapy fail.</li><li>➤ Surgery is only done when 2 attempts of endoscopic therapy fail.</li><li>➤ Surgical management includes duodenotomy and under-running of the vessel.</li><li>➤ Duodenal ulcers also show good response to vagotomy/ acid reduction surgeries.</li><li>➤ Ref : Bailey 28th Ed. Pg 1166-67</li><li>➤ Ref</li><li>➤ : Bailey 28th Ed. Pg 1166-67</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "What classification will you use for the endoscopic appearance of bleeding peptic ulcers?", "options": [{"label": "A", "text": "Rockall score", "correct": false}, {"label": "B", "text": "Bismuth classification", "correct": false}, {"label": "C", "text": "DeMeester scoring system", "correct": false}, {"label": "D", "text": "Forrest classification", "correct": true}], "correct_answer": "D. Forrest classification", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/22/screenshot-2024-03-22-185532.png"], "explanation": "<p><strong>Ans. D) Forrest classification</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: The Rockall score is used to assess the risk of mortality from gastrointestinal bleeding both before and after endoscopy . It includes clinical and endoscopic criteria but is not specific to the classification of ulcer appearance.</li><li>• Option A:</li><li>• Rockall score</li><li>• assess the risk of mortality from gastrointestinal bleeding</li><li>• both before and after endoscopy</li><li>• Option B: The Bismuth-Corlette classification is used for cholangiocarcinomas to describe the anatomical location of these tumors within the biliary tree , not for peptic ulcers.</li><li>• Option B:</li><li>• Bismuth-Corlette classification</li><li>• cholangiocarcinomas</li><li>• anatomical location of these tumors</li><li>• biliary tree</li><li>• Option C: The DeMeester scoring system is used in the evaluation of gastroesophageal reflux disease (GERD) as part of a 24-hour pH monitoring assessment, not for bleeding peptic ulcers.</li><li>• Option C:</li><li>• DeMeester scoring system</li><li>• evaluation of gastroesophageal reflux disease</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ This classification is specifically designed to describe the endoscopic appearance of bleeding peptic ulcers and to stratify the risk of rebleeding based on endoscopic findings . Understanding this classification helps guide clinical management and intervention.</li><li>➤ classification is specifically designed</li><li>➤ endoscopic appearance of bleeding peptic ulcers</li><li>➤ stratify the risk of rebleeding</li><li>➤ endoscopic findings</li><li>➤ Ref : Bailey 28th Ed. Pg 1166-67</li><li>➤ Ref</li><li>➤ : Bailey 28th Ed. Pg 1166-67</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old female with a history of migraine management through NSAID use presents with acute onset of abdominal pain and vomiting. The examination shows generalized tenderness, and her blood work indicates leukocytosis and normal serum lipase. What is the next diagnostic step?", "options": [{"label": "A", "text": "USG abdomen", "correct": false}, {"label": "B", "text": "X-ray abdomen", "correct": true}, {"label": "C", "text": "CECT abdomen", "correct": false}, {"label": "D", "text": "Take up for surgery", "correct": false}], "correct_answer": "B. X-ray abdomen", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) X-ray abdomen</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Ultrasound of the abdomen can be useful in evaluating certain abdominal conditions but may not be the best immediate diagnostic step for suspected perforated peptic ulcer.</li><li>• Option A:</li><li>• Ultrasound of the abdomen</li><li>• useful in evaluating certain abdominal conditions</li><li>• Option C: CECT of the abdomen is the most accurate imaging modality in this scenario to diagnose the suspected peptic ulcer perforation , however will be performed only if X ray missed the free air.</li><li>• Option C:</li><li>• CECT of the abdomen</li><li>• accurate imaging modality</li><li>• diagnose the suspected peptic ulcer perforation</li><li>• Option D: Surgical intervention is typically considered after confirming the diagnosis and the extent of the disease with appropriate imaging. Immediate surgery without confirming the diagnosis may not be warranted at this stage.</li><li>• Option D:</li><li>• Surgical intervention</li><li>• confirming the diagnosis and the extent of the disease</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In a patient with suspected perforated peptic ulcer and signs of peritonitis , X ray abdomen is the initial step , to plan further management, including the possibility of surgical intervention.</li><li>➤ suspected perforated peptic ulcer and signs of peritonitis</li><li>➤ X ray abdomen is the initial step</li><li>➤ The patient, who may have a history of peptic ulceration , develops sudden-onset severe generalized abdominal pain due to the irritant effect of gastric acid on the peritoneum . Although the contents of an acid-producing stomach are relatively low in bacterial load, bacterial peritonitis supervenes over a few hours, usually accompanied by deterioration in the patient’s condition. Initially, the patient may be shocked with tachycardia, but pyrexia is not usually observed until some hours after the event. The abdomen exhibits a board-like rigidity , and the patient is disinclined to move because of the pain. The abdomen does not move with respiration. An erect chest radiograph will reveal free gas under the diaphragm in more than 50% of cases with perforated peptic ulcer , but CT imaging is now commonly used and is more accurate. All patients should have serum amylase performed, as distinguishing between peptic ulcer, perforation, and pancreatitis can be difficult.</li><li>➤ The patient, who may have a history of peptic ulceration , develops sudden-onset severe generalized abdominal pain due to the irritant effect of gastric acid on the peritoneum . Although the contents of an acid-producing stomach are relatively low in bacterial load, bacterial peritonitis supervenes over a few hours, usually accompanied by deterioration in the patient’s condition. Initially, the patient may be shocked with tachycardia, but pyrexia is not usually observed until some hours after the event.</li><li>➤ history of peptic ulceration</li><li>➤ sudden-onset severe generalized abdominal pain</li><li>➤ irritant effect of gastric acid on the peritoneum</li><li>➤ The abdomen exhibits a board-like rigidity , and the patient is disinclined to move because of the pain. The abdomen does not move with respiration.</li><li>➤ board-like rigidity</li><li>➤ An erect chest radiograph will reveal free gas under the diaphragm in more than 50% of cases with perforated peptic ulcer , but CT imaging is now commonly used and is more accurate. All patients should have serum amylase performed, as distinguishing between peptic ulcer, perforation, and pancreatitis can be difficult.</li><li>➤ erect chest radiograph will reveal free gas under the diaphragm</li><li>➤ 50% of cases with perforated peptic ulcer</li><li>➤ Ref : Bailey and Love 28th Ed. Pg 1164-65.</li><li>➤ Ref</li><li>➤ : Bailey and Love 28th Ed. Pg 1164-65.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 35-year-old patient presents with acute severe abdominal pain and vomiting. An abdominal radiograph is done as shown. What is the most appropriate next step in management?", "options": [{"label": "A", "text": "Gastric lavage with cold saline", "correct": false}, {"label": "B", "text": "Tracheostomy", "correct": false}, {"label": "C", "text": "Chest tube insertion", "correct": false}, {"label": "D", "text": "Resuscitation and laparotomy", "correct": true}], "correct_answer": "D. Resuscitation and laparotomy", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/27/picture1_hz8xBVu.png"], "explanation_images": [], "explanation": "<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Gastric lavage with cold saline is not appropriate for a perforated viscus ; it could potentially worsen the situation by increasing the spread of gastric contents within the peritoneal cavity.</li><li>• Option A:</li><li>• Gastric lavage with cold saline</li><li>• not appropriate for a perforated viscus</li><li>• Option B: Tracheostomy is a procedure to secure the airway in cases of upper airway obstruction or long-term ventilation, not indicated in this scenario.</li><li>• Option B:</li><li>• Tracheostomy</li><li>• procedure to secure the airway</li><li>• upper airway obstruction</li><li>• Option C: Chest tube insertion is indicated for pneumothorax or pleural effusion , not for free air under the diaphragm due to an intra-abdominal perforation.</li><li>• Option C:</li><li>• Chest tube insertion</li><li>• pneumothorax or pleural effusion</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ When a patient present with signs of a perforated abdominal viscus , such as free air under the diaphragm, the initial management should include resuscitation followed by surgical intervention through a laparotomy to repair the defect and prevent further contamination of the peritoneal cavity.</li><li>➤ patient present with signs of a perforated abdominal viscus</li><li>➤ free air under the diaphragm,</li><li>➤ initial management</li><li>➤ resuscitation followed by surgical intervention</li><li>➤ The initial priorities are resuscitation and analgesia. Analgesia should not be withheld for fear of removing the signs of an intra-abdominal catastrophe. Adequate analgesia makes the clinical signs more obvious . Following resuscitation, the treatment is principally surgical. Laparotomy is performed, usually through an upper midline incision. The most important component of the operation is a thorough peritoneal toilet to remove all of the fluid and food debris . If the perforation is in the duodenum, it can usually be closed by several well-placed sutures, closing the ulcer in a transverse direction as with a pyloroplasty. It is common to place an omental patch over the perforation in the hope of enhancing the chances of the leak sealing. If the perforation is difficult to close primarily, it is frequently possible to seal the leak with an omental patch alone , and many surgeons now employ this strategy for all perforations. Gastric ulcers should, if possible, be excised and closed, so that malignancy can be excluded. Occasionally, a patient is seen who has a massive duodenal or gastric perforation such that simple closure is impossible. In these patients, a distal gastrectomy with Roux-en-Y reconstruction is the procedure of choice .</li><li>➤ The initial priorities are resuscitation and analgesia. Analgesia should not be withheld for fear of removing the signs of an intra-abdominal catastrophe. Adequate analgesia makes the clinical signs more obvious . Following resuscitation, the treatment is principally surgical. Laparotomy is performed, usually through an upper midline incision.</li><li>➤ analgesia makes the clinical signs more obvious</li><li>➤ The most important component of the operation is a thorough peritoneal toilet to remove all of the fluid and food debris . If the perforation is in the duodenum, it can usually be closed by several well-placed sutures, closing the ulcer in a transverse direction as with a pyloroplasty.</li><li>➤ peritoneal toilet</li><li>➤ to remove all of the fluid and food debris</li><li>➤ It is common to place an omental patch over the perforation in the hope of enhancing the chances of the leak sealing.</li><li>➤ If the perforation is difficult to close primarily, it is frequently possible to seal the leak with an omental patch alone , and many surgeons now employ this strategy for all perforations.</li><li>➤ seal the leak with an omental patch alone</li><li>➤ Gastric ulcers should, if possible, be excised and closed, so that malignancy can be excluded. Occasionally, a patient is seen who has a massive duodenal or gastric perforation such that simple closure is impossible. In these patients, a distal gastrectomy with Roux-en-Y reconstruction is the procedure of choice .</li><li>➤ distal gastrectomy with Roux-en-Y reconstruction is the procedure of choice</li><li>➤ Ref : Bailey and Love 28th Ed. Pg 1165</li><li>➤ Ref</li><li>➤ : Bailey and Love 28th Ed. Pg 1165</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "According to the latest research, what is the most common site of gastric adenocarcinoma in Western countries?", "options": [{"label": "A", "text": "Body", "correct": false}, {"label": "B", "text": "Proximal stomach", "correct": true}, {"label": "C", "text": "Lesser curve", "correct": false}, {"label": "D", "text": "Antrum", "correct": false}], "correct_answer": "B. Proximal stomach", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Proximal stomach</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Gastric adenocarcinoma most commonly affects the antrum of the stomach in non-Western countries , while the incidence of proximal stomach cancers is rising in Western countries, likely related to the increasing incidence of chronic GERD and obesity .</li><li>• Gastric adenocarcinoma</li><li>• affects the antrum of the stomach in non-Western countries</li><li>• increasing incidence of chronic GERD and obesity</li><li>• Other options:</li><li>• Other options:</li><li>• Option D: The antrum , the lower portion of the stomach , is the most common site for gastric adenocarcinoma outside of Western countries.</li><li>• Option D:</li><li>• antrum</li><li>• lower portion of the stomach</li><li>• most common site for gastric adenocarcinoma</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In resource-rich western countries, the proximal stomach is the most common site . Although, worldwide incidence of gastric adenocarcinoma is on a decline, cancer of the proximal stomach is on a rise in western countries. This may be due to the increasing incidence of chronic GERD and obesity in western countries.</li><li>➤ In resource-rich western countries, the proximal stomach is the most common site . Although, worldwide incidence of gastric adenocarcinoma is on a decline, cancer of the proximal stomach is on a rise in western countries. This may be due to the increasing incidence of chronic GERD and obesity in western countries.</li><li>➤ In resource-rich western countries, the proximal stomach is the most common site</li><li>➤ worldwide incidence of gastric adenocarcinoma</li><li>➤ cancer of the proximal stomach is on a rise in western countries.</li><li>➤ Ref : Bailey 28th Ed. Pg 1170</li><li>➤ Ref</li><li>➤ : Bailey 28th Ed. Pg 1170</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is not included in the Rockall scoring system for predicting mortality and rebleeding risk in patients with upper gastrointestinal bleeding?", "options": [{"label": "A", "text": "Forrest grade", "correct": false}, {"label": "B", "text": "Presence of coronary artery disease", "correct": false}, {"label": "C", "text": "Systolic BP", "correct": false}, {"label": "D", "text": "Hemoglobin", "correct": true}], "correct_answer": "D. Hemoglobin", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Hemoglobin</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• This is the correct answer. Hemoglobin level is not included in the Rockall score . The Rockall score is based on age , presence of shock (systolic blood pressure and pulse), comorbidities, diagnosis, and major stigmata of recent hemorrhage on endoscopy. However, the Glasgow-Blatchford score , which is another system used to assess the severity of upper gastrointestinal bleeding , does include hemoglobin and BUN levels , among other factors, but does not take into account endoscopic findings.</li><li>• Hemoglobin level is not included in the Rockall score</li><li>• Rockall score is based on age</li><li>• presence of shock</li><li>• comorbidities, diagnosis, and major stigmata</li><li>• recent hemorrhage on endoscopy.</li><li>• Glasgow-Blatchford score</li><li>• another system used to assess the severity of upper gastrointestinal bleeding</li><li>• hemoglobin and BUN levels</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Rockall scoring system does not include the hemoglobin level . It is designed to predict the risk of mortality and rebleeding in patients with upper gastrointestinal bleeding using variables such as age, blood pressure, comorbidities, diagnosis, and endoscopic findings .</li><li>➤ Rockall scoring system</li><li>➤ not include the hemoglobin level</li><li>➤ designed to predict the risk of mortality and rebleeding</li><li>➤ upper gastrointestinal bleeding</li><li>➤ variables such as age, blood pressure, comorbidities, diagnosis, and endoscopic findings</li><li>➤ The Rockall score can be used in a pre-endoscopy format to stratify patients to save early discharge and, post endoscopy , it can relatively accurately predict rebleeding and death, in patients with peptic ulcer bleed.</li><li>➤ Rockall score</li><li>➤ pre-endoscopy format to stratify patients to save early discharge and, post endoscopy</li><li>➤ Components:</li><li>➤ Components:</li><li>➤ Age Blood pressure Comorbidities (CAD/Liver disease/Renal failure) Diagnosis: Mallory Weiss tear/Malignancy etc. Endoscopic finding (Forrest grade)</li><li>➤ Age</li><li>➤ Blood pressure</li><li>➤ Comorbidities (CAD/Liver disease/Renal failure)</li><li>➤ Diagnosis: Mallory Weiss tear/Malignancy etc.</li><li>➤ Diagnosis:</li><li>➤ Endoscopic finding (Forrest grade)</li><li>➤ NOTE: The Glasgow-Blatchford score includes haemoglobin, BUN but doesn’t account for endoscopic findings.</li><li>➤ NOTE:</li><li>➤ Ref : Bailey and Love 28th Ed. Table 67.5</li><li>➤ Ref</li><li>➤ : Bailey and Love 28th Ed. Table 67.5</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 40-year-old man undergoes endoscopy, revealing multiple gastric polyps. Which of the following statements about gastric polyps is incorrect?", "options": [{"label": "A", "text": "Metaplastic gastric polyps are associated with H. pylori infection", "correct": false}, {"label": "B", "text": "Metaplastic gastric polyps have a strong association with Familial adenomatous polyposis.", "correct": true}, {"label": "C", "text": "Neither metaplastic nor fundic gland polyps have proven malignant potential", "correct": false}, {"label": "D", "text": "Adenomatous polyps have malignant potential", "correct": false}], "correct_answer": "B. Metaplastic gastric polyps have a strong association with Familial adenomatous polyposis.", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Metaplastic gastric polyps have a strong association with Familial adenomatous polyposis.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A: Metaplastic gastric polyps , often referred to as hyperplastic polyps , are indeed associated with H. pylori infection and may regress after eradication therapy . This statement is correct .</li><li>• Option A:</li><li>• Metaplastic gastric polyps</li><li>• hyperplastic polyps</li><li>• H. pylori infection</li><li>• regress after eradication therapy</li><li>• correct</li><li>• Option C: This is a correct statement . Generally, metaplastic (hyperplastic) polyps and fundic gland polyps do not have a significant malignant potential, though they require monitoring.</li><li>• Option C:</li><li>• correct statement</li><li>• metaplastic</li><li>• Option D: This statement is correct . Adenomas (tubular and villous) are seen commonly in colon and rectum, and sometimes in stomach. They have malignant potential.</li><li>• Option D:</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The incorrect statement is Metaplastic gastric polyps (often referred to as hyperplastic polyps) are not strongly associated with Familial adenomatous polyposis ; this association is with fundic gland polyps.</li><li>➤ incorrect statement</li><li>➤ Metaplastic gastric polyps</li><li>➤ not strongly associated with Familial adenomatous polyposis</li><li>➤ fundic gland polyps.</li><li>➤ Gastric polyps may represent early gastric cancer; hence biopsy is essential . The most common type of gastric polyp is metaplastic . Metaplastic or hyperplastic polyps have a strong association with H. pylori infection . They regress following H. pylori eradication therapy. Fundic gland polyps deserve particular attention . They are associated with use of PPIs and are also found in patients with familial adenomatous polyposis (FAP). Neither metaplastic nor fundic gland polyps have proven malignant potential; however, true adenomas do and should be removed.</li><li>➤ Gastric polyps may represent early gastric cancer; hence biopsy is essential . The most common type of gastric polyp is metaplastic .</li><li>➤ Gastric polyps</li><li>➤ biopsy is essential</li><li>➤ The most common type of gastric polyp is metaplastic</li><li>➤ Metaplastic or hyperplastic polyps have a strong association with H. pylori infection . They regress following H. pylori eradication therapy.</li><li>➤ Metaplastic or hyperplastic polyps</li><li>➤ strong association with H. pylori infection</li><li>➤ Fundic gland polyps deserve particular attention . They are associated with use of PPIs and are also found in patients with familial adenomatous polyposis (FAP).</li><li>➤ Fundic gland polyps deserve particular attention</li><li>➤ Neither metaplastic nor fundic gland polyps have proven malignant potential; however, true adenomas do and should be removed.</li><li>➤ Ref : Bailey and love 28 th edition Pg 1169</li><li>➤ Ref</li><li>➤ : Bailey and love 28 th edition Pg 1169</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 65-year-old male presents with early satiety and weight loss. On workup, he is found to have gastric carcinoma. During physical examination, a notable swelling is observed in the left supraclavicular region. This clinical finding is referred to as what sign?", "options": [{"label": "A", "text": "Sister Mary Joseph nodule", "correct": false}, {"label": "B", "text": "Troisier sign", "correct": true}, {"label": "C", "text": "Trousseau sign", "correct": false}, {"label": "D", "text": "Krukenberg’s tumour", "correct": false}], "correct_answer": "B. Troisier sign", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Troisier sign</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Sister Mary Joseph nodules refer to subcutaneous nodules at the umbilicus resulting from intraperitoneal spread of malignant cells , typically from gastrointestinal or gynecological malignancies.</li><li>• Option A:</li><li>• Sister Mary Joseph</li><li>• subcutaneous nodules at the umbilicus</li><li>• intraperitoneal spread of malignant cells</li><li>• Option C : Trousseau sign refers to carpopedal spasm seen in hypocalcemia.</li><li>• Option C</li><li>• Trousseau sign refers to carpopedal spasm seen in hypocalcemia.</li><li>• Trousseau syndrome refers to migratory thrombophlebitis and is a paraneoplastic phenomenon that can be associated with visceral malignancies but is not related to a specific physical swelling or node.</li><li>• Trousseau syndrome</li><li>• migratory thrombophlebitis</li><li>• paraneoplastic phenomenon</li><li>• associated with visceral malignancies</li><li>• Option D: Krukenberg’s tumor is a term for metastatic spread of a gastrointestinal carcinoma , particularly stomach cancer, to the ovaries.</li><li>• Option D:</li><li>• Krukenberg’s tumor</li><li>• metastatic spread of a gastrointestinal carcinoma</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Troisier sign , is enlargement of the left supraclavicular lymph node , which indicates metastasis from an intra-abdominal malignancy such as gastric cancer.</li><li>➤ Troisier sign</li><li>➤ enlargement of the left supraclavicular lymph node</li><li>➤ metastasis from an intra-abdominal malignancy</li><li>➤ gastric cancer.</li><li>➤ Tumors giving rise to Virchow’s node/Troisier’s sign:</li><li>➤ Stomach Colo-rectal Testicular/Ovarian Left breast Left bronchus</li><li>➤ Stomach</li><li>➤ Colo-rectal</li><li>➤ Testicular/Ovarian</li><li>➤ Left breast</li><li>➤ Left bronchus</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1174</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th Ed. Pg 1174</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A female patient presented with fatigue, bloating sensation, and weight loss of around 8 Kg for the past 8 months. After a detailed workup, she was diagnosed with early gastric carcinoma. All of the following structures can be involved in this stage except:", "options": [{"label": "A", "text": "Mucosa", "correct": false}, {"label": "B", "text": "Submucosa", "correct": false}, {"label": "C", "text": "Muscularis propria", "correct": true}, {"label": "D", "text": "Lymph nodes", "correct": false}], "correct_answer": "C. Muscularis propria", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/02/untitled-575.jpg"], "explanation": "<p><strong>Ans. C) Muscularis propria</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Early gastric cancer doesn't involve muscularis propria.</li><li>• Early gastric cancer doesn't involve muscularis propria.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Early gastric carcinoma is defined by the involvement of the mucosa and submucosa, regardless of lymph node involvement , and does not typically extend into the muscularis propria .</li><li>➤ Early gastric carcinoma</li><li>➤ involvement of the mucosa and submucosa,</li><li>➤ lymph node involvement</li><li>➤ does not typically extend into the muscularis propria</li><li>➤ Gastric carcinoma can be classified as early gastric cancer and advanced gastric cancer .</li><li>➤ Gastric carcinoma</li><li>➤ early gastric cancer</li><li>➤ advanced gastric cancer</li><li>➤ Early gastric cancer involves mucosa, submucosa with or without lymph node involvement . This is given by Japanese classification (image below).</li><li>➤ Early gastric cancer involves mucosa, submucosa with or without lymph node involvement . This is given by Japanese classification (image below).</li><li>➤ Early gastric cancer</li><li>➤ mucosa, submucosa with or without lymph node involvement</li><li>➤ Japanese classification</li><li>➤ Advanced gastric cancer involves the muscularis layer, with or without adjacent structures.</li><li>➤ Advanced gastric cancer involves the muscularis layer, with or without adjacent structures.</li><li>➤ Advanced gastric cancer</li><li>➤ Ref : Bailey and Love 28th Ed. Fig 67.25</li><li>➤ Ref</li><li>➤ : Bailey and Love 28th Ed. Fig 67.25</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old chronic smoker presents with symptoms suggestive of gastric outlet obstruction with severe pallor and cachexia. CECT abdomen shows a polypoidal growth into the stomach wall. What Bormann's classification does this belong to?", "options": [{"label": "A", "text": "Type I", "correct": true}, {"label": "B", "text": "Type II", "correct": false}, {"label": "C", "text": "Type III", "correct": false}, {"label": "D", "text": "Type IV", "correct": false}], "correct_answer": "A. Type I", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/02/untitled-576.jpg"], "explanation": "<p><strong>Ans. A) Type I</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Bormann type II refers to a ulcero-proliferative type of growth that projects into the lumen but with less of a polypoid appearance than type I.</li><li>• Option B:</li><li>• Bormann type II</li><li>• ulcero-proliferative type of growth</li><li>• projects into the lumen</li><li>• Option C: Bormann type III is an ulcerative lesion without a significant mass protruding into the gastric lumen.</li><li>• Option C:</li><li>• Bormann type III</li><li>• ulcerative lesion</li><li>• Option D: Bormann type IV is known as linitis plastica or diffuse type , characterized by diffuse infiltration of the stomach wall leading to thickening, typically without forming a discrete mass.</li><li>• Option D:</li><li>• Bormann type IV</li><li>• linitis plastica or diffuse type</li><li>• diffuse infiltration of the stomach wall</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ This classification is important in the staging and management of gastric carcinoma , as it provides information on the extent of the tumor and possible invasion into the muscularis, which is significant for determining prognosis and therapeutic approaches.</li><li>➤ staging and management of gastric carcinoma</li><li>➤ provides information on the extent of the tumor</li><li>➤ possible invasion into the muscularis,</li><li>➤ Ref : Bailey 28th Ed. Pg 1172</li><li>➤ Ref</li><li>➤ : Bailey 28th Ed. Pg 1172</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old male, diagnosed with an early gastric carcinoma is planned for endoscopic mucosal resection. Which of the following features of the tumor would not favor performing this procedure on him?", "options": [{"label": "A", "text": "Tumour measuring 1-2 cm", "correct": false}, {"label": "B", "text": "Moderately well-differentiated tumour", "correct": false}, {"label": "C", "text": "Lympho-vascular invasion", "correct": true}, {"label": "D", "text": "Tumour limited to the mucosa", "correct": false}], "correct_answer": "C. Lympho-vascular invasion", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Lympho-vascular invasion</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Tumors smaller than 2 cm in size are generally considered suitable for EMR , provided other favorable criteria are met.</li><li>• Option A:</li><li>• Tumors smaller than 2 cm</li><li>• size are generally considered suitable for EMR</li><li>• Option B: A tumor that is well to moderately well-differentiated is typically amenable to EMR , as these tumors usually have less aggressive behavior.</li><li>• Option B:</li><li>• tumor that is well to moderately well-differentiated</li><li>• amenable to EMR</li><li>• Option D: A tumor that is confined to the mucosal layer without invading deeper layers is an ideal candidate for EMR, as the risk of lymph node metastasis is minimal.</li><li>• Option D:</li><li>• tumor that is confined to the mucosal layer</li><li>• without invading deeper layers</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In early gastric cancer , EMR is most suitable for tumors that are small , well-differentiated, confined to the mucosa , and without lympho-vascular invasion . The presence of lympho-vascular invasion indicates a higher risk for metastasis , making more extensive surgical options necessary for adequate treatment.</li><li>➤ early gastric cancer</li><li>➤ EMR is most suitable for tumors that are small</li><li>➤ well-differentiated,</li><li>➤ confined to the mucosa</li><li>➤ without lympho-vascular invasion</li><li>➤ presence of lympho-vascular invasion</li><li>➤ higher risk for metastasis</li><li>➤ The general guidelines for endoscopic resection of early gastric cancer are as follows:</li><li>➤ The general guidelines for endoscopic resection of early gastric cancer are as follows:</li><li>➤ Tumour smaller than 2 cm Tumour limited to the mucosa No lympho-vascular invasion No ulceration Well or moderately well-differentiated histopathology.</li><li>➤ Tumour smaller than 2 cm</li><li>➤ Tumour limited to the mucosa</li><li>➤ No lympho-vascular invasion</li><li>➤ No ulceration</li><li>➤ Well or moderately well-differentiated histopathology.</li><li>➤ If any of these is not fulfilled, gastrectomy with lymph node dissection is indicated.</li><li>➤ Ref : Bailey 28th Ed. Pg 1174-76</li><li>➤ Ref</li><li>➤ : Bailey 28th Ed. Pg 1174-76</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the incorrect statement concerning the given condition:", "options": [{"label": "A", "text": "Found in young psychiatric patients.", "correct": false}, {"label": "B", "text": "It can extend into the small bowel in severe case", "correct": false}, {"label": "C", "text": "Treatment is total gastrectomy.", "correct": true}, {"label": "D", "text": "It is caused by the ingestion of hair, which remains undigested in the stomach.", "correct": false}], "correct_answer": "C. Treatment is total gastrectomy.", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/27/picture1_micsGlQ.png"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Treatment is total gastrectomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: This statement is correct . Trichobezoars are typically found in young psychiatric patients due to the ingestion of hair, often in the setting of a condition known as trichophagia.</li><li>• Option A:</li><li>• correct</li><li>• Option B: Trichobezoars can extend to the small bowel , known as Rapunzel syndrome.</li><li>• Option B:</li><li>• Trichobezoars can extend to the small bowel</li><li>• Option D: This statement is correct . Trichobezoars are indeed caused by the ingestion of hair, which can accumulate and remain undigested in the stomach.</li><li>• Option D:</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The standard treatment for a trichobezoar is not total gastrectomy but rather the endoscopic or surgical removal of the bezoar.</li><li>➤ standard treatment for a trichobezoar</li><li>➤ not total gastrectomy</li><li>➤ endoscopic or surgical removal of the bezoar.</li><li>➤ Trichobezoar (hairballs) are unusual and are virtually exclusively found in young psychiatric patients. It is caused by the ingestion of hair, which remains undigested in the stomach. The hairball can lead to ulceration and gastro-intestinal bleeding, perforation or obstruction. The diagnosis is made easily at endoscopy. Treatment consists of removal of the bezoar, which may require open surgical treatment. Phytobezoars are made of vegetable matter and are found principally in patients who have gastric stasis, usually following gastric surgery.</li><li>➤ Trichobezoar (hairballs) are unusual and are virtually exclusively found in young psychiatric patients. It is caused by the ingestion of hair, which remains undigested in the stomach.</li><li>➤ Trichobezoar (hairballs)</li><li>➤ The hairball can lead to ulceration and gastro-intestinal bleeding, perforation or obstruction. The diagnosis is made easily at endoscopy.</li><li>➤ Treatment consists of removal of the bezoar, which may require open surgical treatment.</li><li>➤ Treatment consists of removal of the bezoar, which may require open surgical treatment.</li><li>➤ Phytobezoars are made of vegetable matter and are found principally in patients who have gastric stasis, usually following gastric surgery.</li><li>➤ Ref : Bailey 28 th Ed. Pg 1180</li><li>➤ Ref : Bailey 28 th Ed. Pg 1180</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the incorrect statement about gastric lymphomas:", "options": [{"label": "A", "text": "Primary gastric lymphomas are B-cell derived, the tumor arising from mucosa-associated lymphoid tissue (MALT)", "correct": false}, {"label": "B", "text": "The most common site is the fundus", "correct": true}, {"label": "C", "text": "Early gastric lymphomas may regress and disappear when the Helicobacter infection is treated.", "correct": false}, {"label": "D", "text": "NHL is the most common type of gastric lymphoma.", "correct": false}], "correct_answer": "B. The most common site is the fundus", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Most common site is the fundus</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: This statement is correct . Most primary gastric lymphomas are B-cell lymphomas arising from MALT, and they can remain localized to the stomach for some time before involving lymph nodes.</li><li>• Option A:</li><li>• correct</li><li>• Option C: This statement is correct . There is evidence that early MALT lymphomas associated with Helicobacter pylori infection can regress following successful eradication of the infection.</li><li>• Option C:</li><li>• correct</li><li>• Option D: This statement is also correct . Non-Hodgkin's lymphoma is the most common type of gastric lymphoma, with diffuse large B-cell lymphoma being the most common subtype.</li><li>• Option D:</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The fundus is not the most common site for primary gastric lymphomas ; rather, the antrum is the primary site . Top of Form</li><li>➤ fundus is not the most common site for primary gastric lymphomas</li><li>➤ antrum is the primary site</li><li>➤ Bottom of Form</li><li>➤ Primary gastric lymphomas are B-cell derived , the tumour arising from mucosa-associated lymphoid tissue (MALT). Primary gastric lymphoma remains in the stomach for a prolonged period before involving lymph nodes. At an early stage, the disease takes the form of a diffuse mucosal thickening, which may cause ulceration. NHL is the most common type of gastric lymphoma. Among NHL, the most common type is diffuse large B-cell lymphoma (DLBCL) (55%) , followed by gastric mucosa-associated lymphoid tissue (MALT) lymphoma (40%), Burkitt lymphoma (3%), and mantle cell and follicular lymphomas (each &lt;1%).</li><li>➤ Primary gastric lymphomas are B-cell derived , the tumour arising from mucosa-associated lymphoid tissue (MALT). Primary gastric lymphoma remains in the stomach for a prolonged period before involving lymph nodes. At an early stage, the disease takes the form of a diffuse mucosal thickening, which may cause ulceration.</li><li>➤ Primary gastric lymphomas</li><li>➤ B-cell derived</li><li>➤ tumour arising from mucosa-associated lymphoid tissue</li><li>➤ NHL is the most common type of gastric lymphoma. Among NHL, the most common type is diffuse large B-cell lymphoma (DLBCL) (55%) , followed by gastric mucosa-associated lymphoid tissue (MALT) lymphoma (40%), Burkitt lymphoma (3%), and mantle cell and follicular lymphomas (each &lt;1%).</li><li>➤ diffuse large B-cell lymphoma (DLBCL) (55%)</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1179</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th Ed. Pg 1179</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which gastric lymph node station is designated as number 6 according to the Japanese Classification for Gastric Carcinoma staging system?", "options": [{"label": "A", "text": "Lesser curvature", "correct": false}, {"label": "B", "text": "Greater curvature", "correct": false}, {"label": "C", "text": "Infrapyloric", "correct": true}, {"label": "D", "text": "Left pericardial.", "correct": false}], "correct_answer": "C. Infrapyloric", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/04/12/screenshot-2024-04-12-171623.png"], "explanation": "<p><strong>Ans. C) Infrapyloric</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A : The lesser curvature lymph nodes are labeled as group 3 , not group 6.</li><li>• Option A</li><li>• lesser curvature lymph nodes are labeled as group 3</li><li>• Option B: The greater curvature lymph nodes are referred to as group 4 , not group 6.</li><li>• Option B:</li><li>• greater curvature lymph nodes are referred to as group 4</li><li>• Option D: The left pericardial lymph nodes are indicated as station number 2 , not 6.</li><li>• Option D:</li><li>• left pericardial lymph nodes are indicated as station number 2</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ According to the Japanese Classification for Gastric Carcinoma staging system , Station number 6 , infrapyloric, represents the lymph nodes located below the pylorus of the stomach.</li><li>➤ Japanese Classification for Gastric Carcinoma staging system</li><li>➤ Station number 6</li><li>➤ The Japanese Classification for Gastric Carcinoma (JCGC) staging system divided lymph nodes into 16 groups based on likelihood of metastasis from the primary tumour and removal of lymph nodes during gastrectomy</li><li>➤ Japanese Classification for Gastric Carcinoma</li><li>➤ staging system divided lymph nodes into 16 groups</li><li>➤ Nodes lying close to stomach (perigastric):</li><li>➤ Nodes lying close to stomach (perigastric):</li><li>➤ 1. Right pericardial</li><li>➤ 2. Left pericardial</li><li>➤ 3. Lesser curvature</li><li>➤ 4. Greater curvature</li><li>➤ 5. Suprapyloric</li><li>➤ 6. Infrapyloric</li><li>➤ Truncal nodes:</li><li>➤ Truncal nodes:</li><li>➤ 7. Along the Left gastric artery</li><li>➤ 8a. Along the anterior hepatic artery</li><li>➤ 9. Celiac</li><li>➤ 10. Splenic artery</li><li>➤ 11. Splenic hilum</li><li>➤ Ref : Bailey 28 th Ed. Table 67.6</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Table 67.6</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A chronic smoker presented in the OPD with dysphagia, loss of appetite and pallor. Endoscopy showed the presence of a mass arising from the stomach. Which statement regarding the TNM staging is inaccurate?", "options": [{"label": "A", "text": "In T4, the tumour perforates serosa", "correct": false}, {"label": "B", "text": "In T2, Tumour invades muscularis propria", "correct": false}, {"label": "C", "text": "Dukes staging was used for stomach cancer in the past", "correct": true}, {"label": "D", "text": "Retro-pancreatic and mesenteric nodal spread is M1", "correct": false}], "correct_answer": "C. Dukes staging was used for stomach cancer in the past", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/22/screenshot-2024-03-22-192225.png"], "explanation": "<p><strong>Ans. C) Dukes staging was used for stomach cancer in the past.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: This statement is correct ; T4 staging in the TNM classification does indicate tumor perforation of the serosa.</li><li>• Option A:</li><li>• correct</li><li>• Option B: This statement is also correct ; T2 staging signifies that the tumor has invaded the muscularis propria.</li><li>• Option B:</li><li>• correct</li><li>• Option D: This statement is correct ; the involvement of non-regional lymph nodes, such as retro pancreatic and mesenteric nodes, is classified as M1, indicating distant metastasis.</li><li>• Option D:</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Dukes staging was used for colorectal cancer , not stomach cancer.</li><li>➤ Dukes staging</li><li>➤ colorectal cancer</li><li>➤ TNM staging for lymph node and tumour:</li><li>➤ TNM staging for lymph node and tumour:</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1173</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th Ed. Pg 1173</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In the surgical resection of gastric adenocarcinoma for an obese male, what is the recommended minimum negative margin distance from the tumor?", "options": [{"label": "A", "text": "10 cm", "correct": false}, {"label": "B", "text": "5 cm", "correct": true}, {"label": "C", "text": "3 cm", "correct": false}, {"label": "D", "text": "2 cm", "correct": false}], "correct_answer": "B. 5 cm", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) 5 cm</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ When performing a gastrectomy for adenocarcinoma , a negative margin of at least 5 cm is ideal to decrease the likelihood of local recurrence . Margins should be confirmed with frozen section intraoperatively if there is any doubt about the involvement of the resection margins.</li><li>➤ performing a gastrectomy for adenocarcinoma</li><li>➤ negative margin of at least 5 cm is ideal to decrease the likelihood of local recurrence</li><li>➤ Margins</li><li>➤ frozen section intraoperatively</li><li>➤ In surgical resection of gastric adenocarcinoma, at least 5 cm margin should be removed. Separation of the stomach from the spleen, if it is not going to be removed, allows access to the nodal tissues around the upper stomach and GOJ. It is important that the resection margins are well clear of the tumour (&gt;5 cm). Frozen section should be performed if involvement of either proximal or distal resection margin is in doubt.</li><li>➤ In surgical resection of gastric adenocarcinoma, at least 5 cm margin should be removed.</li><li>➤ at least 5 cm margin should be removed.</li><li>➤ Separation of the stomach from the spleen, if it is not going to be removed, allows access to the nodal tissues around the upper stomach and GOJ.</li><li>➤ It is important that the resection margins are well clear of the tumour (&gt;5 cm). Frozen section should be performed if involvement of either proximal or distal resection margin is in doubt.</li><li>➤ resection margins are well clear of the tumour</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1175</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th Ed. Pg 1175</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "D2 lymphadenectomy for adenocarcinoma of stomach entails removal of which of these groups of LN?", "options": [{"label": "A", "text": "1 to 6", "correct": false}, {"label": "B", "text": "7 to 11", "correct": false}, {"label": "C", "text": "1 to 11", "correct": true}, {"label": "D", "text": "1 to 16", "correct": false}], "correct_answer": "C. 1 to 11", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) 1 to 11</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: A D1 resection typically involves the removal of perigastric nodes , which include stations 1 to 6.</li><li>• Option A:</li><li>• D1 resection</li><li>• removal of perigastric nodes</li><li>• Option B: Groups 7 to 11 are the nodes along the major arterial trunks , and they are included in a D2 resection but not in isolation.</li><li>• Option B:</li><li>• 7 to 11 are the nodes</li><li>• major arterial trunks</li><li>• Option D: Groups 1 to 16 would suggest an even more extensive lymphadenectomy than a standard D2 resection and is not typically performed as it would involve non-regional nodes and nodes removed only in the setting of a more radical surgery.</li><li>• Option D:</li><li>• 1 to 16 would suggest an even more extensive lymphadenectomy</li><li>• standard D2 resection</li><li>• involve non-regional nodes and nodes removed only in the setting of a more radical surgery.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ A D2 lymphadenectomy in gastric adenocarcinoma includes the removal of perigastric lymph nodes (stations 1 to 6) and nodes along the major arterial trunks (stations 7 to 11), providing a more extensive clearance than a D1 lymphadenectomy, which could potentially improve oncological outcomes for patients with locally advanced disease.</li><li>➤ D2 lymphadenectomy</li><li>➤ gastric adenocarcinoma</li><li>➤ removal of perigastric lymph nodes</li><li>➤ nodes along the major arterial trunks</li><li>➤ more extensive clearance than a D1 lymphadenectomy,</li><li>➤ The differentiation between a D1 and a D2 operation depends upon the tiers of nodes removed. In general, a D1 resection involves the removal of the perigastric nodes and a D2 resection involves the clearance of the major arterial trunks. In practice the majority of specialist centres will perform a radical total gastrectomy, conserving the spleen and pancreas, with D2 lymphadenectomy sparing station 10 lymph nodes. D1: Perigastric nodes: station 1 to 6 D2: Perigastric and truncal nodes: 1 to 6 and 7 to 11. The nodes in stations 12–18 are not routinely removed in D1 or D2 gastrectomy.</li><li>➤ The differentiation between a D1 and a D2 operation depends upon the tiers of nodes removed.</li><li>➤ In general, a D1 resection involves the removal of the perigastric nodes and a D2 resection involves the clearance of the major arterial trunks.</li><li>➤ In general, a D1 resection involves the removal of the perigastric nodes and a D2 resection involves the clearance of the major arterial trunks.</li><li>➤ In practice the majority of specialist centres will perform a radical total gastrectomy, conserving the spleen and pancreas, with D2 lymphadenectomy sparing station 10 lymph nodes.</li><li>➤ D1: Perigastric nodes: station 1 to 6</li><li>➤ D1:</li><li>➤ D2: Perigastric and truncal nodes: 1 to 6 and 7 to 11.</li><li>➤ D2:</li><li>➤ The nodes in stations 12–18 are not routinely removed in D1 or D2 gastrectomy.</li><li>➤ Ref : Bailey and Love 28th Ed. Table 67.7</li><li>➤ Ref</li><li>➤ : Bailey and Love 28th Ed. Table 67.7</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "“They are tumours of mesenchymal origin and are observed equally commonly in males and females. The tumours are universally associated with a mutation in the tyrosine kinase c-kit oncogene.” Which tumour is being described here?", "options": [{"label": "A", "text": "Gastric lymphomas", "correct": false}, {"label": "B", "text": "MALToma", "correct": false}, {"label": "C", "text": "GIST", "correct": true}, {"label": "D", "text": "Zollinger Ellison syndrome", "correct": false}], "correct_answer": "C. GIST", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) GIST</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Gastric lymphomas are malignancies of the lymphatic system , not mesenchymal tumors, and are not associated with c-kit mutations.</li><li>• Option A:</li><li>• Gastric lymphomas</li><li>• malignancies of the lymphatic system</li><li>• Option B: MALToma , or mucosa-associated lymphoid tissue lymphoma , is a type of cancer involving the immune system's lymphocytes and is not related to c-kit mutations.</li><li>• Option B:</li><li>• MALToma</li><li>• mucosa-associated lymphoid tissue lymphoma</li><li>• type of cancer</li><li>• Option D: Zollinger-Ellison syndrome is a condition caused by gastrin-secreting tumors leading to excessive gastric acid production and is not associated with c-kit or GISTs.</li><li>• Option D:</li><li>• Zollinger-Ellison syndrome</li><li>• gastrin-secreting tumors</li><li>• excessive gastric acid production</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract , often associated with mutations in the c-kit gene .</li><li>➤ Gastrointestinal stromal tumors</li><li>➤ most common mesenchymal tumors</li><li>➤ gastrointestinal tract</li><li>➤ mutations in the c-kit gene</li><li>➤ Previously named leiomyoma and leiomyosarcoma , are tumours of mesenchymal origin and are observed equally commonly in males and females. The tumours are universally associated with a mutation in the tyrosine kinase c-kit oncogene . They originate from pacemaker cells of the stomach (Cells of Cajal). These tumours are sensitive to the tyrosine kinase antagonist imatinib, and an 80% objective response rate can be observed. They show CD 117 and CD 34 IHC markers. Size &gt; 5 cm and mitotic index are the best predictors of metastasis . Peritoneal and liver metastases are most common but spread to lymph nodes is extremely rare. Many GISTs are noticed incidentally at endoscopy or diagnosed if the overlying mucosa ulcerates with bleeding and anaemia. If easily resectable surgery is the primary mode of treatment. Smaller tumours can be treated by wedge excision. Adjuvant imatinib for resected tumours of high malignant potential should probably be continued indefinitely.</li><li>➤ Previously named leiomyoma and leiomyosarcoma , are tumours of mesenchymal origin and are observed equally commonly in males and females.</li><li>➤ leiomyoma and leiomyosarcoma</li><li>➤ The tumours are universally associated with a mutation in the tyrosine kinase c-kit oncogene . They originate from pacemaker cells of the stomach (Cells of Cajal).</li><li>➤ tyrosine kinase c-kit oncogene</li><li>➤ (Cells of Cajal).</li><li>➤ These tumours are sensitive to the tyrosine kinase antagonist imatinib, and an 80% objective response rate can be observed.</li><li>➤ They show CD 117 and CD 34 IHC markers.</li><li>➤ They show CD 117 and CD 34 IHC markers.</li><li>➤ Size &gt; 5 cm and mitotic index are the best predictors of metastasis .</li><li>➤ Size &gt; 5 cm and mitotic index are the best predictors of metastasis</li><li>➤ Peritoneal and liver metastases are most common but spread to lymph nodes is extremely rare.</li><li>➤ Many GISTs are noticed incidentally at endoscopy or diagnosed if the overlying mucosa ulcerates with bleeding and anaemia.</li><li>➤ If easily resectable surgery is the primary mode of treatment. Smaller tumours can be treated by wedge excision.</li><li>➤ Smaller tumours can be treated by wedge excision.</li><li>➤ Adjuvant imatinib for resected tumours of high malignant potential should probably be continued indefinitely.</li><li>➤ Ref : Bailey and Love 28 th Ed Pg 1178</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th Ed Pg 1178</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following statements is false regarding intestinal type of gastric carcinoma?", "options": [{"label": "A", "text": "It is well differentiated.", "correct": false}, {"label": "B", "text": "It is associated with gastric atrophy.", "correct": false}, {"label": "C", "text": "It primarily spreads through lymphatic channels.", "correct": true}, {"label": "D", "text": "It is more common in men.", "correct": false}], "correct_answer": "C. It primarily spreads through lymphatic channels.", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) It primarily spreads through lymphatic channels.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A : Intestinal-type gastric carcinoma is often well differentiated, which correlates with the formation of glandular structures.</li><li>• Option A</li><li>• Intestinal-type gastric carcinoma</li><li>• well differentiated,</li><li>• Option B: This type of cancer is associated with conditions like gastric atrophy and chronic gastritis , which can lead to the metaplastic changes that precede cancer.</li><li>• Option B:</li><li>• type of cancer is associated with conditions like gastric atrophy</li><li>• chronic gastritis</li><li>• Option D: It is indeed more common in men and often occurs in an older age group.</li><li>• Option D:</li><li>• more common in men</li><li>• older age group.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Intestinal-type gastric carcinoma typically spreads hematogenously, often to the liver, whereas lymphatic spread is a feature of diffuse-type gastric carcinoma.</li><li>➤ Intestinal-type gastric carcinoma</li><li>➤ spreads hematogenously,</li><li>➤ liver,</li><li>➤ lymphatic spread is a feature of diffuse-type gastric carcinoma.</li><li>➤ Intestinal type:</li><li>➤ Intestinal type:</li><li>➤ Elderly, males APC mutation Protruding type Hematogenous metastasis Good prognosis</li><li>➤ Elderly, males</li><li>➤ APC mutation</li><li>➤ APC mutation</li><li>➤ Protruding type</li><li>➤ Hematogenous metastasis</li><li>➤ Good prognosis</li><li>➤ Diffuse type:</li><li>➤ Diffuse type:</li><li>➤ Young, females Decreased E cadherin Flat/depressed Signet cells Lymphatic metastasis Poor prognosis</li><li>➤ Young, females</li><li>➤ Decreased E cadherin</li><li>➤ Decreased E cadherin</li><li>➤ Flat/depressed</li><li>➤ Signet cells</li><li>➤ Lymphatic metastasis</li><li>➤ Poor prognosis</li><li>➤ Poor prognosis</li><li>➤ Ref : Bailey and Love 28th Ed. Pg 1170</li><li>➤ Ref</li><li>➤ : Bailey and Love 28th Ed. Pg 1170</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In Siewart’s classification of gastroesophageal (GE) junction tumors, which description corresponds to a true GE junction tumor?", "options": [{"label": "A", "text": "Located between 5 cm and 1 cm above GE junction", "correct": false}, {"label": "B", "text": "Located between 2 cm above and 1 cm below GE junction", "correct": false}, {"label": "C", "text": "Located between 1 cm above and 2 cm below GE junction", "correct": true}, {"label": "D", "text": "Located between 1 cm above and 1 cm below GE junction", "correct": false}], "correct_answer": "C. Located between 1 cm above and 2 cm below GE junction", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/22/screenshot-2024-03-22-192920.png"], "explanation": "<p><strong>Ans. C) Located between 1 cm above and 2 cm below GE junction</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Siewart’s classification of GE junction tumors (adenocarcinomas):</li><li>• Siewart’s classification of GE junction tumors (adenocarcinomas):</li><li>• Siewart type 2 are true GE junction tumors.</li><li>• Siewart type 2 are true GE junction tumors.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Tumors located between 1 cm above and 2 cm below the GE junction are classified as Siewart type 2 and are considered b</li><li>➤ Tumors</li><li>➤ between 1 cm above and 2 cm below the GE junction</li><li>➤ Siewart type 2</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient who is a known case of Crohn's disease underwent terminal ileal resection for the presence of stricture. Several months later, he presents to the clinic with a history of a tingling sensation of hands and the peripheral smear shows the presence of macrocytic anemia. What is the most likely cause?", "options": [{"label": "A", "text": "Vitamin B1 deficiency", "correct": false}, {"label": "B", "text": "Vitamin B12 deficiency", "correct": true}, {"label": "C", "text": "Folic acid deficiency", "correct": false}, {"label": "D", "text": "Calcium deficiency", "correct": false}], "correct_answer": "B. Vitamin B12 deficiency", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Vitamin B12 deficiency</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A : Vitamin B1 (thiamine) deficiency can cause neurological and cardiac symptoms , but it is not typically associated with macrocytic anemia.</li><li>• Option A</li><li>• Vitamin B1</li><li>• deficiency</li><li>• neurological and cardiac symptoms</li><li>• not typically associated with macrocytic anemia.</li><li>• Option C : While folic acid deficiency can cause macrocytic anemia , it doesn't typically cause the neurological symptoms described and is more often linked to dietary deficiencies or malabsorption syndromes not specific to the terminal ileum.</li><li>• Option C</li><li>• folic acid deficiency</li><li>• cause macrocytic anemia</li><li>• doesn't typically cause the neurological symptoms</li><li>• more often linked to dietary deficiencies</li><li>• malabsorption syndromes</li><li>• Option D : Calcium deficiency can lead to neuromuscular irritability and osteoporosis but is not typically associated with macrocytic anemia.</li><li>• Option D</li><li>• Calcium deficiency</li><li>• neuromuscular irritability</li><li>• osteoporosis</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ Following resection of the terminal ileum , a patient may develop vitamin B12 deficiency due to the loss of specific receptors located there, which can lead to macrocytic anemia and neurological symptoms like paresthesias .</li><li>➤ Following resection</li><li>➤ terminal ileum</li><li>➤ develop vitamin B12 deficiency due to the loss of specific receptors</li><li>➤ which can lead to macrocytic anemia</li><li>➤ neurological symptoms like paresthesias</li><li>➤ The absorption of bile salts and vitamin B12 only occurs in the terminal ileum, where there are specific transporters. If the jejunum is resected, the ileum can assume all the required absorptive functions. Resection of the terminal ileum will result in a diminished bile salt pool, and vitamin B12 deficiency and may lead to deficiency of the fat-soluble vitamins A, D, E, and K.</li><li>➤ The absorption of bile salts and vitamin B12 only occurs in the terminal ileum, where there are specific transporters.</li><li>➤ If the jejunum is resected, the ileum can assume all the required absorptive functions.</li><li>➤ Resection of the terminal ileum will result in a diminished bile salt pool, and vitamin B12 deficiency and may lead to deficiency of the fat-soluble vitamins A, D, E, and K.</li><li>➤ Ref : Bailey and Love, 28 th Ed. pg 1307</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. pg 1307</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is a false statement about small bowel anatomy?", "options": [{"label": "A", "text": "Jejunum has a wider lumen and longer vasa recta", "correct": false}, {"label": "B", "text": "Ileum is usually 60% of the total small bowel length", "correct": false}, {"label": "C", "text": "Ligament of Treitz marks DJ flexure", "correct": false}, {"label": "D", "text": "Ileal resections are better tolerated than jejunal resections", "correct": true}], "correct_answer": "D. Ileal resections are better tolerated than jejunal resections", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/10/f_OaTcyCa.jpg"], "explanation": "<p><strong>Ans. D) Ileal resections are better tolerated than jejunal resections.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A: This statement is true . The jejunum typically has a wider lumen and longer vasa recta when compared to the ileum.</li><li>• Option A: This statement is true</li><li>• jejunum</li><li>• wider lumen and longer vasa recta</li><li>• Option B: This is also true . The ileum is generally around 60% of the total small bowel length .</li><li>• Option B: This is also true</li><li>• ileum is generally around 60%</li><li>• total small bowel length</li><li>• Option C: True . The ligament of Treitz is an anatomical landmark indicating the location where the duodenum transitions to the jejunum, also known as the duodenojejunal (DJ) flexure .</li><li>• Option C: True</li><li>• ligament of Treitz</li><li>• duodenojejunal (DJ) flexure</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ In the anatomy and physiology of the small intestine , the ileum's unique absorptive roles make ileal resections less well-tolerated than jejunal resections .</li><li>➤ anatomy and physiology of the small intestine</li><li>➤ ileum's unique absorptive roles make ileal resections less well-tolerated</li><li>➤ jejunal resections</li><li>➤ Total length - 350-800 cm Jejunum - 40%, wider lumen, longer vasa recta Ileum - 60%, thicker mesentery, branched vasa recta The jejunum is the principal site for digestion and absorption of fluid, electrolytes, iron, folate, fat, protein and carbohydrate. The ileum also plays an important role in water absorption, possibly because the tightness of the intercellular junctions supports a concentration gradient across its lumen. Significant ileal resection therefore commonly results in very troublesome Diarrhoea.</li><li>➤ Total length - 350-800 cm</li><li>➤ Total length -</li><li>➤ 350-800 cm</li><li>➤ Jejunum - 40%, wider lumen, longer vasa recta</li><li>➤ Ileum - 60%, thicker mesentery, branched vasa recta</li><li>➤ The jejunum is the principal site for digestion and absorption of fluid, electrolytes, iron, folate, fat, protein and carbohydrate.</li><li>➤ The ileum also plays an important role in water absorption, possibly because the tightness of the intercellular junctions supports a concentration gradient across its lumen. Significant ileal resection therefore commonly results in very troublesome Diarrhoea.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1306-07</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1306-07</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 3-year-old boy with a history of failure to thrive during infancy was brought to the casualty with fever, abdominal pain with distension, and bilious vomiting for 20 days. Which of these is incorrect about midgut malrotation?", "options": [{"label": "A", "text": "Caecum and appendix lie on the left", "correct": false}, {"label": "B", "text": "Surgery is done for acute intestinal obstruction", "correct": false}, {"label": "C", "text": "Appendicectomy is done even if appendix is normal", "correct": false}, {"label": "D", "text": "During surgery, caecum is fixed to the right", "correct": true}], "correct_answer": "D. During surgery, caecum is fixed to the right", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/23/screenshot-2024-03-23-120902.png", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/23/screenshot-2024-03-23-121141.png"], "explanation": "<p><strong>Ans. D) During surgery, caecum is fixed to the right</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A: This is correct . In cases of midgut malrotation, the cecum and appendix are often located on the left due to abnormal rotation and fixation of the intestines.</li><li>• Option A: This is correct</li><li>• Option B: Correct . Acute intestinal obstruction in midgut malrotation leading to volvulus is a surgical emergency and requires prompt intervention to prevent complications like ischemic damage to the intestines.</li><li>• Option B: Correct</li><li>• Option C: Correct . An incidental appendectomy is typically performed during surgery for midgut malrotation to prevent future diagnostic confusion since the appendix may not be located in its usual position.</li><li>• Option C: Correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The surgery , known as Ladd's procedure , involves detorsion if volvulus is present , division of Ladd's bands , broadening of the mesentery , incidental appendectomy , and placement of the small bowel on the right and the colon on the left to prevent future volvulus.</li><li>➤ surgery</li><li>➤ Ladd's procedure</li><li>➤ detorsion if volvulus is present</li><li>➤ division of Ladd's bands</li><li>➤ broadening of the mesentery</li><li>➤ incidental appendectomy</li><li>➤ placement of the small bowel</li><li>➤ right and the colon on the left</li><li>➤ Malrotated midgut : Entire small bowel lies on right, caecum in epigastrium and colon on left. Ladd’s band attached cecum to right abdominal wall and cause duodenal compression. Malrotation can be asymptomatic or may be manifested as chronic abdominal pain, with bilious vomiting and failure to thrive . Mid-gut malrotation may get complicated by twist/volvulus of small bowel leading to acute intestinal obstruction. Typical finding of midgut volvulus - acute onset of bilious vomiting. An acute small bowel volvulus suspected in an acidotic baby, vomiting bile with a gasless abdominal radiograph and a scaphoid abdomen demands an immediate laparotomy. Well babies presenting with bilious vomiting have a contrast study to locate the DJ flexure. If the DJ flexure lies to the left of the vertebral column, at the level of the pylorus, the mesentery is likely to be stable. At operation, the bowel is placed in the non-rotated position and the mesentery is broadened – Ladd’s procedure. Surgery – Ladd’s procedure</li><li>➤ Malrotated midgut : Entire small bowel lies on right, caecum in epigastrium and colon on left. Ladd’s band attached cecum to right abdominal wall and cause duodenal compression.</li><li>➤ Malrotated midgut</li><li>➤ Malrotation can be asymptomatic or may be manifested as chronic abdominal pain, with bilious vomiting and failure to thrive .</li><li>➤ Malrotation can be asymptomatic</li><li>➤ manifested as chronic abdominal pain, with bilious vomiting and failure to thrive</li><li>➤ Mid-gut malrotation may get complicated by twist/volvulus of small bowel leading to acute intestinal obstruction.</li><li>➤ Typical finding of midgut volvulus - acute onset of bilious vomiting.</li><li>➤ An acute small bowel volvulus suspected in an acidotic baby, vomiting bile with a gasless abdominal radiograph and a scaphoid abdomen demands an immediate laparotomy.</li><li>➤ Well babies presenting with bilious vomiting have a contrast study to locate the DJ flexure. If the DJ flexure lies to the left of the vertebral column, at the level of the pylorus, the mesentery is likely to be stable. At operation, the bowel is placed in the non-rotated position and the mesentery is broadened – Ladd’s procedure.</li><li>➤ Surgery – Ladd’s procedure</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28th edition, pg 267</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28th edition, pg 267</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "The most common site for intestinal tuberculosis is?", "options": [{"label": "A", "text": "Distal ileum", "correct": true}, {"label": "B", "text": "Jejunum", "correct": false}, {"label": "C", "text": "Ascending colon", "correct": false}, {"label": "D", "text": "Sigmoid colon", "correct": false}], "correct_answer": "A. Distal ileum", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Distal ileum</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Intestinal tuberculosis most commonly affects the ileocecal region and may present with a variety of symptoms including abdominal pain, weight loss, and fever . The disease can manifest in two forms , ulcerative and hyperplastic , with the ulcerative form often being secondary to pulmonary tuberculosis.</li><li>➤ Intestinal tuberculosis</li><li>➤ affects the ileocecal region</li><li>➤ present with a variety of symptoms</li><li>➤ abdominal pain, weight loss, and fever</li><li>➤ two forms</li><li>➤ ulcerative and hyperplastic</li><li>➤ Ulcerative tuberculosis develops secondary to pulmonary tuberculosis and arises as a result of swallowing tubercle bacilli . Multiple ulcers, lying transversely, develop in the terminal ileum and the overlying serosa is thickened, reddened and covered in tubercles. Hyperplastic is caused by the ingestion of Mycobacterium tuberculosis by patients with a high resistance to the organism. The infection usually occurs in the ileocecal region, although solitary and multiple lesions in the distal ileum are also sometimes seen.</li><li>➤ Ulcerative tuberculosis develops secondary to pulmonary tuberculosis and arises as a result of swallowing tubercle bacilli . Multiple ulcers, lying transversely, develop in the terminal ileum and the overlying serosa is thickened, reddened and covered in tubercles.</li><li>➤ Ulcerative tuberculosis develops secondary to pulmonary tuberculosis and arises as a result of swallowing tubercle bacilli . Multiple ulcers, lying transversely, develop in the terminal ileum and the overlying serosa is thickened, reddened and covered in tubercles.</li><li>➤ Ulcerative tuberculosis</li><li>➤ secondary to pulmonary tuberculosis</li><li>➤ arises as a result of swallowing tubercle bacilli</li><li>➤ Hyperplastic is caused by the ingestion of Mycobacterium tuberculosis by patients with a high resistance to the organism. The infection usually occurs in the ileocecal region, although solitary and multiple lesions in the distal ileum are also sometimes seen.</li><li>➤ Hyperplastic is caused by the ingestion of Mycobacterium tuberculosis by patients with a high resistance to the organism. The infection usually occurs in the ileocecal region, although solitary and multiple lesions in the distal ileum are also sometimes seen.</li><li>➤ Hyperplastic</li><li>➤ ingestion of Mycobacterium tuberculosis</li><li>➤ high resistance to the organism.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1308</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1308</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 26-year-old female patient present with attacks of abdominal pain and intermittent diarrhea. There is steatorrhea, anemia and loss of weight. Patient also has a mass in the right iliac fossa. A barium study shows the following: What is your probable diagnosis?", "options": [{"label": "A", "text": "Appendix carcinoid", "correct": false}, {"label": "B", "text": "Amebic typhlitis", "correct": false}, {"label": "C", "text": "Ileocecal TB", "correct": true}, {"label": "D", "text": "Ulcerative colitis", "correct": false}], "correct_answer": "C. Ileocecal TB", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/10/picture3_ALm8BaJ.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Ileocecal TB</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation :</li><li>• Option A : Appendix carcinoid typically does not present with the systemic symptoms described or the specific radiologic findings seen in this barium study.</li><li>• Option A</li><li>• Appendix carcinoid</li><li>• does not present with the systemic symptoms</li><li>• Option B : Amebic typhlitis may cause similar symptoms but would not typically result in the pulled-up cecum seen on the barium study.</li><li>• Option B</li><li>• Amebic typhlitis</li><li>• similar symptoms but would not typically result in the pulled-up cecum</li><li>• Option D : Ulcerative colitis usually involves the colon and would not typically present with a pulled-up cecum, or the systemic symptoms described.</li><li>• Option D</li><li>• Ulcerative colitis</li><li>• colon</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ Ileocecal TB is characterized by systemic symptoms like weight loss and anemia , local findings such as a mass in the right iliac fossa , and specific radiologic signs in the barium study indicative of TB involvement in the ileocecal region .</li><li>➤ Ileocecal TB</li><li>➤ systemic symptoms like weight loss and anemia</li><li>➤ local findings</li><li>➤ mass in the right iliac fossa</li><li>➤ radiologic signs in the barium study</li><li>➤ TB involvement</li><li>➤ ileocecal region</li><li>➤ Patients usually present with attacks of abdominal pain and intermittent diarrhea . There is incomplete ileal obstruction , leading to stasis and bacterial overgrowth. This in turn causes steatorrhea, anemia and loss of weight. Patients may present with a mass in the right iliac fossa and vague ill health . The differential diagnosis is that of an appendix mass, lymphoma, carcinoma of the caecum, CD, tuberculosis or actinomycosis. A barium follow-through or small bowel enema will show a long narrow filling defect in the terminal ileum (which may result in a differential diagnosis of CD). CT will also demonstrate the narrowed segment with proximal distension and the associated lymphadenopathy.</li><li>➤ Patients usually present with attacks of abdominal pain and intermittent diarrhea . There is incomplete ileal obstruction , leading to stasis and bacterial overgrowth. This in turn causes steatorrhea, anemia and loss of weight.</li><li>➤ Patients usually present with attacks of abdominal pain and intermittent diarrhea . There is incomplete ileal obstruction , leading to stasis and bacterial overgrowth. This in turn causes steatorrhea, anemia and loss of weight.</li><li>➤ Patients usually present with attacks of abdominal pain and intermittent diarrhea</li><li>➤ incomplete ileal obstruction</li><li>➤ stasis and bacterial overgrowth.</li><li>➤ Patients may present with a mass in the right iliac fossa and vague ill health . The differential diagnosis is that of an appendix mass, lymphoma, carcinoma of the caecum, CD, tuberculosis or actinomycosis.</li><li>➤ Patients may present with a mass in the right iliac fossa and vague ill health . The differential diagnosis is that of an appendix mass, lymphoma, carcinoma of the caecum, CD, tuberculosis or actinomycosis.</li><li>➤ present with a mass in the right iliac fossa</li><li>➤ vague ill health</li><li>➤ A barium follow-through or small bowel enema will show a long narrow filling defect in the terminal ileum (which may result in a differential diagnosis of CD). CT will also demonstrate the narrowed segment with proximal distension and the associated lymphadenopathy.</li><li>➤ A barium follow-through or small bowel enema will show a long narrow filling defect in the terminal ileum (which may result in a differential diagnosis of CD). CT will also demonstrate the narrowed segment with proximal distension and the associated lymphadenopathy.</li><li>➤ barium follow-through or small bowel enema</li><li>➤ long narrow filling defect in the terminal ileum</li><li>➤ Barium study</li><li>➤ Barium study</li><li>➤ 1. Acute-to-subacute stage</li><li>➤ Acute-to-subacute stage</li><li>➤ Narrowing of the terminal ileum (string sign of Kantor) Thickening and gaping of the ileocecal valve Thickening and hypermotility of the caecum</li><li>➤ Narrowing of the terminal ileum (string sign of Kantor)</li><li>➤ Narrowing of the terminal ileum (string sign of Kantor)</li><li>➤ Thickening and gaping of the ileocecal valve</li><li>➤ Thickening and gaping of the ileocecal valve</li><li>➤ Thickening and hypermotility of the caecum</li><li>➤ Thickening and hypermotility of the caecum</li><li>➤ 2. Chronic stage</li><li>➤ Chronic stage</li><li>➤ Ileo-cecal valve appears fixed, rigid and incompetent. caecum appears conical in shape and shrunken in size. Pulled-up caecum (away from the right iliac fossa) due to fibrotic changes in the mesocolon.</li><li>➤ Ileo-cecal valve appears fixed, rigid and incompetent.</li><li>➤ Ileo-cecal valve appears fixed, rigid and incompetent.</li><li>➤ caecum appears conical in shape and shrunken in size.</li><li>➤ caecum appears conical in shape and shrunken in size.</li><li>➤ Pulled-up caecum (away from the right iliac fossa) due to fibrotic changes in the mesocolon.</li><li>➤ Pulled-up caecum (away from the right iliac fossa) due to fibrotic changes in the mesocolon.</li><li>➤ Ref : Bailey and Love 28 th ed., pg 1308</li><li>➤ Ref : Bailey and Love 28 th ed., pg 1308</li><li>➤ Online article: https://doi.org/10.53347/rID-27606</li><li>➤ Online article:</li><li>➤ https://doi.org/10.53347/rID-27606</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of these findings are common to both intestinal TB and Crohn’s disease, except?", "options": [{"label": "A", "text": "Biopsy shows granulomatous inflammation", "correct": false}, {"label": "B", "text": "Diarrhoea is an early symptom", "correct": false}, {"label": "C", "text": "Perianal disease is characterized by multiple fistulae in ano", "correct": false}, {"label": "D", "text": "c-ASCA and fecal calprotectin are elevated", "correct": true}], "correct_answer": "D. c-ASCA and fecal calprotectin are elevated", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) C-ASCA and Fecal Calprotectin are elevated</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation :</li><li>• Option A : Both intestinal tuberculosis (TB) and Crohn's disease can show granulomatous inflammation on biopsy , making this a common finding rather than an exception.</li><li>• Option A</li><li>• Both intestinal tuberculosis</li><li>• Crohn's disease</li><li>• show granulomatous inflammation on biopsy</li><li>• Option B : Diarrhea is often an early symptom in both conditions due to inflammation , ulceration and disruption of normal bowel function .</li><li>• Option B</li><li>• Diarrhea</li><li>• early symptom in both conditions</li><li>• inflammation</li><li>• ulceration</li><li>• disruption of normal bowel function</li><li>• Option C : While perianal disease characterized by multiple fistulae in ano is more commonly associated with Crohn's disease , it may occasionally be seen in intestinal TB.</li><li>• Option C</li><li>• perianal disease</li><li>• multiple fistulae in ano</li><li>• more commonly associated with Crohn's disease</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective :</li><li>➤ c-ASCA and fecal calprotectin is typically elevated in inflammatory bowel diseases like Crohn's disease and not in intestinal TB.</li><li>➤ c-ASCA and fecal calprotectin is typically elevated in inflammatory bowel diseases like Crohn's disease and not in intestinal TB.</li><li>➤ Similarities between Intestinal TB and Crohn’s:</li><li>➤ Affect terminal ileum commonly Characterized by ulcers Granulomatous inflammation is seen Can affect any part of GIT Stricture, perforation and fistulation seen Presentation is diarrhea or intestinal obstruction Similar findings on contrast imaging: String sign, Sterlin sign</li><li>➤ Affect terminal ileum commonly</li><li>➤ Affect terminal ileum commonly</li><li>➤ Characterized by ulcers</li><li>➤ Characterized by ulcers</li><li>➤ Granulomatous inflammation is seen</li><li>➤ Granulomatous inflammation is seen</li><li>➤ Can affect any part of GIT</li><li>➤ Can affect any part of GIT</li><li>➤ Stricture, perforation and fistulation seen</li><li>➤ Stricture, perforation and fistulation seen</li><li>➤ Presentation is diarrhea or intestinal obstruction</li><li>➤ Presentation is diarrhea or intestinal obstruction</li><li>➤ Similar findings on contrast imaging: String sign, Sterlin sign</li><li>➤ Similar findings on contrast imaging: String sign, Sterlin sign</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1328-29</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1328-29</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 30-year-old male presented with abdominal pain and mild diarrhoea. A tender mass is palpable in the right iliac fossa. Intermittent fever, anaemia and weight loss were also found. On resection of a part of the ileum, the following \"cobble-stone\" appearance was seen. What is your most likely diagnosis?", "options": [{"label": "A", "text": "Intestinal TB", "correct": false}, {"label": "B", "text": "Polyposis", "correct": false}, {"label": "C", "text": "Diverticultis", "correct": false}, {"label": "D", "text": "Crohn’s disease", "correct": true}], "correct_answer": "D. Crohn’s disease", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/10/picture4_kwWWtaF.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. D) Crohn’s disease</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A : Intestinal TB can mimic Crohn's disease but usually presents with systemic symptoms of tuberculosis and features like night sweats and a positive tuberculosis test.</li><li>• Option A</li><li>• Intestinal TB</li><li>• mimic Crohn's disease</li><li>• presents with systemic symptoms of tuberculosis</li><li>• Option B : Polyposis syndromes typically present with multiple polyps throughout the gastrointestinal tract , not with the cobblestone appearance seen in Crohn's.</li><li>• Option B</li><li>• Polyposis syndromes</li><li>• multiple polyps</li><li>• gastrointestinal tract</li><li>• Option C : Diverticulitis does not typically present with the \"cobblestone \" mucosa characteristic of Crohn's disease. It commonly affects sigmoid colon and not terminal ileum.</li><li>• Option C</li><li>• Diverticulitis</li><li>• not typically present with the \"cobblestone</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Crohn's is a chronic inflammatory condition with a pathognomonic feature of non-caseating granulomas and may require a combination of medical and surgical treatments based on severity and complications. Characteristic \"cobblestone\" mucosa and longitudinal ulcerations on an intestinal resection are indicative of Crohn's disease .</li><li>➤ chronic inflammatory condition</li><li>➤ pathognomonic feature of non-caseating granulomas</li><li>➤ may require a combination of medical and surgical treatments</li><li>➤ Characteristic \"cobblestone\" mucosa</li><li>➤ longitudinal ulcerations</li><li>➤ intestinal resection</li><li>➤ Crohn's disease</li><li>➤ Etiology : Genetic + environmental factors (smoking, hygiene hypothesis, M paratuberculosis bacteria).</li><li>➤ Etiology</li><li>➤ Genetic + environmental factors</li><li>➤ Salient Features :</li><li>➤ Salient Features</li><li>➤ Can affect any part of GI from mouth to Anus, typical site is terminal ileum.</li><li>➤ 1. Cut section :</li><li>➤ Cut</li><li>➤ section</li><li>➤ Ulcers Skip lesions with normal mucosa in the middle (cobblestone)</li><li>➤ Ulcers</li><li>➤ Ulcers</li><li>➤ Skip lesions with normal mucosa in the middle (cobblestone)</li><li>➤ Skip lesions with normal mucosa in the middle (cobblestone)</li><li>➤ 2. Microscopy :</li><li>➤ Microscopy</li><li>➤ Microscopically focal areas of chronic inflammation involving all layers of the intestinal wall with lymphoid aggregates are characteristic of CD. Non-caseating giant cell granulomas found in 60% of patients are pathognomonic of CD. They are most commonly seen in anorectal disease.</li><li>➤ Microscopically focal areas of chronic inflammation involving all layers of the intestinal wall with lymphoid aggregates are characteristic of CD. Non-caseating giant cell granulomas found in 60% of patients are pathognomonic of CD. They are most commonly seen in anorectal disease.</li><li>➤ Microscopically focal areas of chronic inflammation involving all layers of the intestinal wall with lymphoid aggregates are characteristic of CD. Non-caseating giant cell granulomas found in 60% of patients are pathognomonic of CD. They are most commonly seen in anorectal disease.</li><li>➤ 3. Clinical features :</li><li>➤ Clinical features</li><li>➤ Diarrhea Pain Bleeding</li><li>➤ Diarrhea</li><li>➤ Diarrhea</li><li>➤ Pain</li><li>➤ Pain</li><li>➤ Bleeding</li><li>➤ Bleeding</li><li>➤ 4. Extra intestinal manifestations: Uveitis, Arthropathy</li><li>➤ 5. Diagnosis : c-ASCA andfecal calprotectin elevated + CECT abdomen/Colonoscopy with biopsy</li><li>➤ Diagnosis</li><li>➤ Treatment :</li><li>➤ Treatment</li><li>➤ Medical : acute exacerbation: steroids Chronic : start with sulfasalazine –immunosuppressants: anti TNF agents Surgery : resection in presence of stricture and disconnect the enterocutaneous fistula if present.</li><li>➤ Medical : acute exacerbation: steroids</li><li>➤ Medical : acute exacerbation: steroids</li><li>➤ Medical</li><li>➤ Chronic : start with sulfasalazine –immunosuppressants: anti TNF agents</li><li>➤ Chronic : start with sulfasalazine –immunosuppressants: anti TNF agents</li><li>➤ Chronic</li><li>➤ Surgery : resection in presence of stricture and disconnect the enterocutaneous fistula if present.</li><li>➤ Surgery : resection in presence of stricture and disconnect the enterocutaneous fistula if present.</li><li>➤ Surgery</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "An 8-year-old boy presents with bleeding in his stools and right iliac fossa pain. USG abdomen is normal. Barium meal follow-through findings are as shown. What is the treatment of the condition?", "options": [{"label": "A", "text": "lV antibiotics", "correct": false}, {"label": "B", "text": "Wedge resection", "correct": true}, {"label": "C", "text": "Mikulicz stricturoplasty", "correct": false}, {"label": "D", "text": "Resection and anastomosis", "correct": false}], "correct_answer": "B. Wedge resection", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/10/picture5_AqOOW7J.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B) Wedge resection</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A : IV antibiotics would be indicated for an infectious process , which is less likely given the imaging and clinical presentation.</li><li>• Option A</li><li>• IV antibiotics</li><li>• indicated for an infectious process</li><li>• Option C : Mikulicz strictureplasty is a surgical procedure used in Crohn's disease to address strictures without removing sections of the intestine, not typically used for Meckel's diverticulum.</li><li>• Option C</li><li>• Mikulicz strictureplasty</li><li>• surgical procedure used in Crohn's disease</li><li>• Option D : Resection and anastomosis is a more extensive surgery that might be indicated if there were complications like perforation or in broad based Meckel’s diverticulum.</li><li>• Option D</li><li>• Resection and anastomosis</li><li>• extensive surgery that might be indicated if there were complications</li><li>• perforation</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Meckel's diverticulum is a potential cause of gastrointestinal bleeding in children and typically requires surgical intervention with a diverticulectomy or wedge resection of the affected area .</li><li>➤ Meckel's diverticulum</li><li>➤ potential cause of gastrointestinal bleeding</li><li>➤ children</li><li>➤ surgical intervention with a diverticulectomy or wedge resection of the affected area</li><li>➤ Note : When found in the course of abdominal surgery, a Meckel's diverticulum can safely be left alone, provided it has a wide mouth and is not thickened. When there is doubt, it can be resected.</li><li>➤ Note</li><li>➤ Ref : Bailey and Love, 28 th Ed Pg. 1311- 1312</li><li>➤ Ref : Bailey and Love, 28 th Ed Pg. 1311- 1312</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "During diagnostic laparoscopy for chronic abdominal pain, small bowel was noted to have findings as shown. What is the likely diagnosis?", "options": [{"label": "A", "text": "TB", "correct": false}, {"label": "B", "text": "Crohn’s disease", "correct": true}, {"label": "C", "text": "Diverticulitis", "correct": false}, {"label": "D", "text": "Ulcerative colitis", "correct": false}], "correct_answer": "B. Crohn’s disease", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/10/picture6_H1DDmJr.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B) Crohn’s disease</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A. TB : Tuberculosis can affect the gastrointestinal tract and may mimic Crohn's disease ; however, the presence of creeping fat is more characteristic of Crohn's.</li><li>• Option A. TB</li><li>• Tuberculosis</li><li>• gastrointestinal tract</li><li>• may mimic Crohn's disease</li><li>• presence of creeping fat</li><li>• characteristic of Crohn's.</li><li>• Option C. Diverticulitis : Diverticulitis typically affects the sigmoid colon and is characterized by the presence of inflamed diverticula , not the small bowel changes seen in the image.</li><li>• Option C. Diverticulitis</li><li>• Diverticulitis</li><li>• sigmoid colon and is characterized by the presence of inflamed diverticula</li><li>• Option D. Ulcerative colitis : Ulcerative colitis is limited to the colon and rectum and is characterized by continuous, superficial inflammation of the colonic mucosa , not the transmural, segmental inflammation seen in Crohn's disease.</li><li>• Option D. Ulcerative colitis</li><li>• limited to the colon and rectum and is characterized by continuous, superficial inflammation of the colonic mucosa</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Creeping fat , thickened bowel walls , and narrowing of the lumen are indicative of Crohn's disease and help distinguish it from other conditions like tuberculosis , diverticulitis, and ulcerative colitis .</li><li>➤ Creeping fat</li><li>➤ thickened bowel walls</li><li>➤ narrowing of the lumen</li><li>➤ Crohn's disease</li><li>➤ conditions like tuberculosis</li><li>➤ diverticulitis, and ulcerative colitis</li><li>➤ The terminal ileum is the most commonly affected segment of bowel in patients with CD, often occurring in combination with other areas of disease. More proximal small bowel is less frequently involved. Colitis alone occurs in up to one-third of cases, the stomach and duodenum are affected in around 5% of cases, but perianal lesions are common, affecting up to 50% of patients. Perianal disease occurs in 25% of patients with small bowel disease and in 75% of patients with Crohn’s colitis. Macroscopically CD is characterized by fibrotic thickening of the intestinal wall with narrowing (structuring) of the lumen and fat wrapping (encroachment of mesenteric fat around the bowel). There is usually a dilated bowel just proximal to the stricture and deep mucosal ulcerations with linear or serpiginous (snake-like) patterns in the stricture area itself. Oedema between ulcers gives rise to a characteristic cobblestone appearance of the mucosa.</li><li>➤ The terminal ileum is the most commonly affected segment of bowel in patients with CD, often occurring in combination with other areas of disease. More proximal small bowel is less frequently involved.</li><li>➤ The terminal ileum is the most commonly affected segment of bowel in patients with CD, often occurring in combination with other areas of disease. More proximal small bowel is less frequently involved.</li><li>➤ Colitis alone occurs in up to one-third of cases, the stomach and duodenum are affected in around 5% of cases, but perianal lesions are common, affecting up to 50% of patients. Perianal disease occurs in 25% of patients with small bowel disease and in 75% of patients with Crohn’s colitis.</li><li>➤ Colitis alone occurs in up to one-third of cases, the stomach and duodenum are affected in around 5% of cases, but perianal lesions are common, affecting up to 50% of patients. Perianal disease occurs in 25% of patients with small bowel disease and in 75% of patients with Crohn’s colitis.</li><li>➤ Macroscopically CD is characterized by fibrotic thickening of the intestinal wall with narrowing (structuring) of the lumen and fat wrapping (encroachment of mesenteric fat around the bowel).</li><li>➤ Macroscopically CD is characterized by fibrotic thickening of the intestinal wall with narrowing (structuring) of the lumen and fat wrapping (encroachment of mesenteric fat around the bowel).</li><li>➤ There is usually a dilated bowel just proximal to the stricture and deep mucosal ulcerations with linear or serpiginous (snake-like) patterns in the stricture area itself. Oedema between ulcers gives rise to a characteristic cobblestone appearance of the mucosa.</li><li>➤ There is usually a dilated bowel just proximal to the stricture and deep mucosal ulcerations with linear or serpiginous (snake-like) patterns in the stricture area itself. Oedema between ulcers gives rise to a characteristic cobblestone appearance of the mucosa.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1327.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1327.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is incorrect about Crohn’s disease (CD)?", "options": [{"label": "A", "text": "Primary sclerosing cholangitis is a common extra-intestinal manifestation", "correct": true}, {"label": "B", "text": "Montreal classification is used in patients with Crohn’s for disease manifestation", "correct": false}, {"label": "C", "text": "Surgery will not cure CD", "correct": false}, {"label": "D", "text": "Perianal CD is typically characterized by abscess", "correct": false}], "correct_answer": "A. Primary sclerosing cholangitis is a common extra-intestinal manifestation", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Primary sclerosing cholangitis is a common extra-intestinal manifestation</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation :</li><li>• Option B : The Montreal classification is utilized for Crohn's disease to categorize the disease based on the age at diagnosis , the behavior of the disease , and its anatomical location . This classification aids in understanding the patient's disease course and in making therapeutic decisions.</li><li>• Option B</li><li>• Montreal classification</li><li>• utilized for Crohn's disease</li><li>• categorize the disease based on the age at diagnosis</li><li>• behavior of the disease</li><li>• anatomical location</li><li>• Option C : Surgery for CD is not curative and is typically reserved for managing complications such as strictures , fistulas , or abscesses since CD is a chronic condition with the potential for relapse and reoccurrence after surgery.</li><li>• Option C</li><li>• Surgery for CD is not curative</li><li>• reserved for managing complications such as strictures</li><li>• fistulas</li><li>• abscesses since CD is a chronic condition</li><li>• Option D : Perianal disease in CD commonly presents with abscess formation , which may lead to complex fistulae , requiring both medical and sometimes surgical management.</li><li>• Option D</li><li>• Perianal disease</li><li>• CD commonly presents with abscess formation</li><li>• lead to complex fistulae</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ While surgery is an important tool for managing complications of CD , it is not a curative treatment due to the chronic and relapsing nature of the disease .</li><li>➤ surgery is an important tool for managing complications of CD</li><li>➤ not a curative treatment</li><li>➤ chronic and relapsing nature of the disease</li><li>➤ The extraintestinal manifestations of CD are similar to those that occur in UC. Primary sclerosing cholangitis is relatively rare in CD, compared with UC. Gallstones are common, as an inflamed or absent (because of resection) terminal ileum leads to reduced absorption of bile salts. Amyloidosis is common but is rarely symptomatic. Each patient with CD should have their disease phenotype (manifestations) classified according to the Montreal classification. This is important as it allows an overview of disease progression in the individual patient over time, and enables group comparisons and evaluations. The Montreal classification specifies age at diagnosis, behaviour and disease location. Perianal CD is distressing and often debilitating for patients. The most common presentation is with a perianal abscess : perianal swelling, redness and pain, followed by discharge of pus or fecal drainage to perianal skin or vagina, implying fistulae. Surgical resection will not cure CD. Surgery, therefore, focuses on managing the complications of the disease. The fundamental principle is to preserve a healthy gut and to maintain adequate function. Intestinal resection should be kept to the minimum required to treat the local consequences of disease to mitigate against the potential for short bowel syndrome .</li><li>➤ The extraintestinal manifestations of CD are similar to those that occur in UC. Primary sclerosing cholangitis is relatively rare in CD, compared with UC. Gallstones are common, as an inflamed or absent (because of resection) terminal ileum leads to reduced absorption of bile salts. Amyloidosis is common but is rarely symptomatic.</li><li>➤ The extraintestinal manifestations of CD are similar to those that occur in UC. Primary sclerosing cholangitis is relatively rare in CD, compared with UC. Gallstones are common, as an inflamed or absent (because of resection) terminal ileum leads to reduced absorption of bile salts. Amyloidosis is common but is rarely symptomatic.</li><li>➤ Each patient with CD should have their disease phenotype (manifestations) classified according to the Montreal classification. This is important as it allows an overview of disease progression in the individual patient over time, and enables group comparisons and evaluations. The Montreal classification specifies age at diagnosis, behaviour and disease location.</li><li>➤ Each patient with CD should have their disease phenotype (manifestations) classified according to the Montreal classification. This is important as it allows an overview of disease progression in the individual patient over time, and enables group comparisons and evaluations. The Montreal classification specifies age at diagnosis, behaviour and disease location.</li><li>➤ Perianal CD is distressing and often debilitating for patients. The most common presentation is with a perianal abscess : perianal swelling, redness and pain, followed by discharge of pus or fecal drainage to perianal skin or vagina, implying fistulae.</li><li>➤ Perianal CD is distressing and often debilitating for patients. The most common presentation is with a perianal abscess : perianal swelling, redness and pain, followed by discharge of pus or fecal drainage to perianal skin or vagina, implying fistulae.</li><li>➤ The most common presentation is with a perianal abscess</li><li>➤ Surgical resection will not cure CD. Surgery, therefore, focuses on managing the complications of the disease. The fundamental principle is to preserve a healthy gut and to maintain adequate function. Intestinal resection should be kept to the minimum required to treat the local consequences of disease to mitigate against the potential for short bowel syndrome .</li><li>➤ Surgical resection will not cure CD. Surgery, therefore, focuses on managing the complications of the disease. The fundamental principle is to preserve a healthy gut and to maintain adequate function. Intestinal resection should be kept to the minimum required to treat the local consequences of disease to mitigate against the potential for short bowel syndrome .</li><li>➤ Intestinal resection should be kept to the minimum required to treat the local consequences of disease to mitigate against the potential for short bowel syndrome</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1329-31</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1329-31</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 16-year-old girl with a history of travel for a trek complained of fever and abdominal discomfort 1 week after returning. She was observed to have splenomegaly and leukopenia by her clinician. In the course of the disease, she had an acute abdominal event and died. Which of the following is the likely finding in the autopsy to suggest a typhoid ulcer perforation?", "options": [{"label": "A", "text": "Transverse ulcers", "correct": false}, {"label": "B", "text": "Longitudinal ulcers", "correct": true}, {"label": "C", "text": "Pin-point ulcers", "correct": false}, {"label": "D", "text": "Pseudo polyps", "correct": false}], "correct_answer": "B. Longitudinal ulcers", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Longitudinal ulcers</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A : Transverse ulcers are not typical of typhoid fever and are more commonly associated with conditions like inflammatory bowel disease (Crohn's disease) or TB.</li><li>• Option A</li><li>• Transverse ulcers</li><li>• not typical of typhoid fever</li><li>• Option C : Pin-point ulcers are not typical of typhoid fever but may be seen in conditions like ischemic colitis.</li><li>• Option C</li><li>• Pin-point ulcers</li><li>• not typical of typhoid fever</li><li>• Option D : Pseudopolyps are associated with inflammatory bowel diseases , such as ulcerative colitis, and are not a feature of typhoid fever.</li><li>• Option D</li><li>• Pseudopolyps</li><li>• inflammatory bowel diseases</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The clinical presentation and complications of typhoid fever , including the presence of longitudinal ulcers that may lead to life-threatening complications such as intestinal perforation.</li><li>➤ clinical presentation and complications of typhoid fever</li><li>➤ presence of longitudinal ulcers</li><li>➤ life-threatening complications such as intestinal perforation.</li><li>➤ Typhoid fever is caused by Salmonella and presents with fever and abdominal pain after an incubation period of 10–20 days . Over the next week, the patient can develop distension, diarrhoea, splenomegaly and characteristic ‘rose spots’ on the abdomen caused by a vasculitis. Typhoid is a systemic infection and diagnosis of typhoid is confirmed by culture of blood or stool . Treatment is by antibiotics, usually chloramphenicol. Many surgical complications can result, including paralytic ileus, intestinal hemorrhage, free ileal perforation and cholecystitis. Invasion of the systemic circulation , which is a characteristic feature of salmonellosis , may cause severe Gram-negative sepsis , resulting in septic shock . Some patients develop metastatic sepsis , including septic arthritis and osteomyelitis, meningitis, encephalitis, disseminated intravascular coagulation and pancreatitis . Perforation of a typhoid ulcer characteristically occurs during the third week of the illness, although it is sometimes the first clinical sign of the disease. The ulcer is parallel to the long axis of the gut and is usually situated in the distal ileum. Perforation requires surgery to wash out and close the ulcer and intestinal resection is usually avoided. Diagnosis of bowel perforation secondary to typhoid:</li><li>➤ Typhoid fever is caused by Salmonella and presents with fever and abdominal pain after an incubation period of 10–20 days . Over the next week, the patient can develop distension, diarrhoea, splenomegaly and characteristic ‘rose spots’ on the abdomen caused by a vasculitis.</li><li>➤ Typhoid fever is caused by Salmonella and presents with fever and abdominal pain after an incubation period of 10–20 days . Over the next week, the patient can develop distension, diarrhoea, splenomegaly and characteristic ‘rose spots’ on the abdomen caused by a vasculitis.</li><li>➤ Typhoid fever</li><li>➤ Salmonella and presents with fever and abdominal pain</li><li>➤ incubation period of 10–20 days</li><li>➤ Typhoid is a systemic infection and diagnosis of typhoid is confirmed by culture of blood or stool . Treatment is by antibiotics, usually chloramphenicol.</li><li>➤ Typhoid is a systemic infection and diagnosis of typhoid is confirmed by culture of blood or stool . Treatment is by antibiotics, usually chloramphenicol.</li><li>➤ Typhoid is a systemic infection</li><li>➤ diagnosis of typhoid is confirmed</li><li>➤ blood or stool</li><li>➤ Many surgical complications can result, including paralytic ileus, intestinal hemorrhage, free ileal perforation and cholecystitis.</li><li>➤ Many surgical complications can result, including paralytic ileus, intestinal hemorrhage, free ileal perforation and cholecystitis.</li><li>➤ Invasion of the systemic circulation , which is a characteristic feature of salmonellosis , may cause severe Gram-negative sepsis , resulting in septic shock .</li><li>➤ Invasion of the systemic circulation , which is a characteristic feature of salmonellosis , may cause severe Gram-negative sepsis , resulting in septic shock .</li><li>➤ Invasion of the systemic circulation</li><li>➤ characteristic feature of salmonellosis</li><li>➤ Gram-negative sepsis</li><li>➤ septic shock</li><li>➤ Some patients develop metastatic sepsis , including septic arthritis and osteomyelitis, meningitis, encephalitis, disseminated intravascular coagulation and pancreatitis .</li><li>➤ Some patients develop metastatic sepsis , including septic arthritis and osteomyelitis, meningitis, encephalitis, disseminated intravascular coagulation and pancreatitis .</li><li>➤ metastatic sepsis</li><li>➤ septic arthritis and osteomyelitis, meningitis, encephalitis, disseminated intravascular coagulation and pancreatitis</li><li>➤ Perforation of a typhoid ulcer characteristically occurs during the third week of the illness, although it is sometimes the first clinical sign of the disease. The ulcer is parallel to the long axis of the gut and is usually situated in the distal ileum. Perforation requires surgery to wash out and close the ulcer and intestinal resection is usually avoided.</li><li>➤ Perforation of a typhoid ulcer characteristically occurs during the third week of the illness, although it is sometimes the first clinical sign of the disease. The ulcer is parallel to the long axis of the gut and is usually situated in the distal ileum. Perforation requires surgery to wash out and close the ulcer and intestinal resection is usually avoided.</li><li>➤ Diagnosis of bowel perforation secondary to typhoid:</li><li>➤ Diagnosis of bowel perforation secondary to typhoid:</li><li>➤ The patient presents in, or has recently visited, an endemic area. The patient has persistent high temperature and is very toxic. Positive blood or stool cultures for Salmonella typhi. After the second week, signs of peritonitis usually denote perforation, which is confirmed by the presence of free gas seen on a radiograph.</li><li>➤ The patient presents in, or has recently visited, an endemic area.</li><li>➤ The patient presents in, or has recently visited, an endemic area.</li><li>➤ The patient has persistent high temperature and is very toxic.</li><li>➤ The patient has persistent high temperature and is very toxic.</li><li>➤ Positive blood or stool cultures for Salmonella typhi.</li><li>➤ Positive blood or stool cultures for Salmonella typhi.</li><li>➤ After the second week, signs of peritonitis usually denote perforation, which is confirmed by the presence of free gas seen on a radiograph.</li><li>➤ After the second week, signs of peritonitis usually denote perforation, which is confirmed by the presence of free gas seen on a radiograph.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1308</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1308</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Most common location of Carcinoids from the below sites is?", "options": [{"label": "A", "text": "Lung", "correct": false}, {"label": "B", "text": "Liver", "correct": false}, {"label": "C", "text": "Appendix", "correct": true}, {"label": "D", "text": "Small bowel", "correct": false}], "correct_answer": "C. Appendix", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/23/screenshot-2024-03-23-123010.png"], "explanation": "<p><strong>Ans. C) Appendix</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Carcinoid tumors are a type of neuroendocrine tumor that can be found throughout the body . They are most commonly located in the gastrointestinal tract , but they can also occur in the lungs and other sites . The appendix is indeed the most common location for carcinoid tumors , which is consistent with the answer provided.</li><li>• Carcinoid tumors</li><li>• type of neuroendocrine tumor</li><li>• found throughout the body</li><li>• most commonly located in the gastrointestinal tract</li><li>• occur in the lungs and other sites</li><li>• appendix is indeed the most common location for carcinoid tumors</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Distribution of Carcinoid tumours:</li><li>➤ Ref : Bailey and Love, 28 th Ed. Table 57.6</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Table 57.6</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of the following statements about carcinoid tumors are true except?", "options": [{"label": "A", "text": "Midgut carcinoids are the most common NETs", "correct": false}, {"label": "B", "text": "Chronic abdominal pain is the most frequent initial symptom.", "correct": false}, {"label": "C", "text": "Chromogranin A is the most specific marker for the diagnosis of carcinoid", "correct": true}, {"label": "D", "text": "Only patients without distant metastases are potential candidates for curative surgery of the primary tumor", "correct": false}], "correct_answer": "C. Chromogranin A is the most specific marker for the diagnosis of carcinoid", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Chromogranin A is the most specific marker for diagnosis of carcinoid</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A : This is correct . Midgut carcinoids are indeed the most common type of NETs, and they typically present later in life.</li><li>• Option A</li><li>• correct</li><li>• Option B : This is correct . Chronic abdominal pain is often the first symptom that prompts further investigation leading to the diagnosis of a carcinoid tumor.</li><li>• Option B</li><li>• correct</li><li>• Option D : This is correct . Patients without distant metastases are potential candidates for curative surgery, which can include resection of the primary tumor and regional lymph nodes.</li><li>• Option D</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Chromogranin A can be elevated in carcinoid tumors , it is not the most specific marker ; instead, urinary 5-HIAA levels are more specific for the diagnosis.</li><li>➤ Chromogranin A</li><li>➤ elevated in carcinoid tumors</li><li>➤ not the most specific marker</li><li>➤ urinary 5-HIAA levels</li><li>➤ Midgut carcinoids are the most common NETs with a peak age of diagnosis at 60–70 years. They are the second most common small bowel malignancy. They arise from the enterochromaffin cells and secrete serotonin and substance P. They are either solitary or multiple (30%) Chronic abdominal pain is the most frequent initial symptom . The carcinoid syndrome is seen in 20–30% of patients with liver metastases. Up to 20% of patients are diagnosed during the investigation of liver metastases or they may be incidentally found during surgery for another reason (laparotomy or appendicectomy). Cross-sectional CT or MRI often shows the mesenteric lymph nodes with a characteristic spiraling of vessels trapped in the desmoplastic reaction In the search for a primary tumour, CT and/or MRI is followed by 68Ga-DOTATOC PET, fused with CT. Biopsy is diagnostic and Ki-67 grading is an important prognostic factor Patients without distant metastases (stages I–III) are all potential candidates for curative surgery of the primary tumour and regional nodal metastases. Concomitant cholecystectomy should be considered owing to the risk of gallstone formation secondary to Somatostatin analogues (SSAs). In the presence of stage IV (metastatic disease) surgery is contemplated when the patient has obstructive symptoms (palliative) or if an R0 resection (curative) can be achieved with concomitant liver metastasectomy. In this setting, patients should have preoperative protection with intravenous SSAs to avoid a carcinoid crisis. Medically, SSAs are an effective treatment for syndrome control for functional NET’s.</li><li>➤ Midgut carcinoids are the most common NETs with a peak age of diagnosis at 60–70 years. They are the second most common small bowel malignancy.</li><li>➤ Midgut carcinoids are the most common NETs with a peak age of diagnosis at 60–70 years.</li><li>➤ They arise from the enterochromaffin cells and secrete serotonin and substance P. They are either solitary or multiple (30%)</li><li>➤ Chronic abdominal pain is the most frequent initial symptom . The carcinoid syndrome is seen in 20–30% of patients with liver metastases.</li><li>➤ Up to 20% of patients are diagnosed during the investigation of liver metastases or they may be incidentally found during surgery for another reason (laparotomy or appendicectomy).</li><li>➤ Cross-sectional CT or MRI often shows the mesenteric lymph nodes with a characteristic spiraling of vessels trapped in the desmoplastic reaction</li><li>➤ mesenteric lymph nodes with a characteristic spiraling of vessels trapped in the desmoplastic reaction</li><li>➤ In the search for a primary tumour, CT and/or MRI is followed by 68Ga-DOTATOC PET, fused with CT.</li><li>➤ Biopsy is diagnostic and Ki-67 grading is an important prognostic factor</li><li>➤ Patients without distant metastases (stages I–III) are all potential candidates for curative surgery of the primary tumour and regional nodal metastases.</li><li>➤ Concomitant cholecystectomy should be considered owing to the risk of gallstone formation secondary to Somatostatin analogues (SSAs).</li><li>➤ In the presence of stage IV (metastatic disease) surgery is contemplated when the patient has obstructive symptoms (palliative) or if an R0 resection (curative) can be achieved with concomitant liver metastasectomy. In this setting, patients should have preoperative protection with intravenous SSAs to avoid a carcinoid crisis.</li><li>➤ Medically, SSAs are an effective treatment for syndrome control for functional NET’s.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 910-911</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 910-911</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Tuberculosis can affect any part of the body, and also affects the small intestine, mainly at the ileo-cecal junction. Treatment involves the use of anti-tubercular drugs, and surgery is seldom done. In which of the following cases will you do surgery for ileocecal TB?", "options": [{"label": "A", "text": "Mucosal ulcerations", "correct": false}, {"label": "B", "text": "Mass in abdomen", "correct": false}, {"label": "C", "text": "Acute obstruction", "correct": true}, {"label": "D", "text": "Frequent diarrhoea", "correct": false}], "correct_answer": "C. Acute obstruction", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Acute obstruction</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• A course of anti-tuberculous chemotherapy usually leads to cure , provided the pulmonary tuberculosis is adequately treated . Surgery is usually undertaken only in the rare event of a perforation or complete intestinal obstruction . Other scenarios such as ulceration, mass (hyperplastic cecal TB) or frequent diarrhoea are also medically managed.</li><li>• A course of anti-tuberculous chemotherapy usually leads to cure , provided the pulmonary tuberculosis is adequately treated . Surgery is usually undertaken only in the rare event of a perforation or complete intestinal obstruction .</li><li>• A course of anti-tuberculous chemotherapy usually leads to cure , provided the pulmonary tuberculosis is adequately treated . Surgery is usually undertaken only in the rare event of a perforation or complete intestinal obstruction .</li><li>• course of anti-tuberculous chemotherapy</li><li>• leads to cure</li><li>• pulmonary tuberculosis</li><li>• adequately treated</li><li>• Surgery</li><li>• rare event of a perforation</li><li>• complete intestinal obstruction</li><li>• Other scenarios such as ulceration, mass (hyperplastic cecal TB) or frequent diarrhoea are also medically managed.</li><li>• Other scenarios such as ulceration, mass (hyperplastic cecal TB) or frequent diarrhoea are also medically managed.</li><li>• ulceration, mass</li><li>• frequent diarrhoea</li><li>• Educational objective :</li><li>• Educational objective</li><li>• If the patient has features of subacute intermittent obstruction , bowel resection , in the form of limited ileocolic resection with anastomosis between the terminal ileum and ascending colon for ileocolic hyperplastic disease , strictureplasty for single ileal stricture , bowel resection for multiple closely placed strictures or right hemicolectomy for extensive ileocolic disease precluding limited resection, is performed as deemed appropriate.</li><li>• subacute intermittent obstruction</li><li>• bowel resection</li><li>• form of limited ileocolic resection</li><li>• anastomosis</li><li>• terminal ileum and ascending colon for ileocolic hyperplastic disease</li><li>• strictureplasty</li><li>• single ileal stricture</li><li>• bowel resection for multiple closely placed strictures</li><li>• Ref : Bailey and Love, 28 th Ed. Pg 89, 1308</li><li>• Ref : Bailey and Love, 28 th Ed. Pg 89, 1308</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the mismatch about CD and Ulcerative colitis?", "options": [{"label": "A", "text": "A", "correct": false}, {"label": "B", "text": "B", "correct": true}, {"label": "C", "text": "C", "correct": false}, {"label": "D", "text": "D", "correct": false}], "correct_answer": "B. B", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/23/screenshot-2024-03-23-124151.png"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/23/screenshot-2024-03-23-124536.png", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/23/screenshot-2024-03-23-124638.png"], "explanation": "<p><strong>Ans. B) B</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 19-year-old woman with a family history of autosomal dominant gastrointestinal polyps presents for evaluation due to noticing dark freckle-like spots inside her mouth and on her lips, which she reports having since childhood. She also mentions intermittent episodes of abdominal pain and occasional blood-streaked stools. On examination, numerous pigmented macules are noted on her lips, oral mucosa, and fingers. Colonoscopy reveals multiple polyps in her colon. Which of the following statements is FALSE regarding the syndrome this patient most likely has?", "options": [{"label": "A", "text": "It is associated with an increased risk of colorectal cancer.", "correct": false}, {"label": "B", "text": "The condition is characterized by the presence of neoplastic polyps predominantly in the colon.", "correct": true}, {"label": "C", "text": "It is linked with an increased risk of various other gastrointestinal and extraintestinal malignancies, including pancreatic cancer.", "correct": false}, {"label": "D", "text": "It is related to a mutation in the STK11 gene on chromosome 19.", "correct": false}], "correct_answer": "B. The condition is characterized by the presence of neoplastic polyps predominantly in the colon.", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/10/picture7_zfhUHyc.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B) The condition is characterized by the presence of neoplastic polyps predominantly in the colon</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation :</li><li>• Option A : This is a true statement ; patients with PJS have an increased lifetime risk of colorectal cancer. Despite the increased risk of malignancy in general, malignant change in the polyps themselves is uncommon.</li><li>• Option A</li><li>• true statement</li><li>• Option C : True , PJS is associated with an increased risk for several types of cancer, including pancreatic cancer.</li><li>• Option C</li><li>• True</li><li>• Option D : True , a mutation in the STK11 gene is associated with PJS.</li><li>• Option D</li><li>• True</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The clinical features and genetic associations of Peutz-Jeghers syndrome , include the polyps are hamartomatous rather than neoplastic .</li><li>➤ genetic associations of Peutz-Jeghers syndrome</li><li>➤ polyps are hamartomatous</li><li>➤ neoplastic</li><li>➤ This is an autosomal dominant condition characterized by melanosis of the mouth and lips , with multiple hamartomatous (benign tumour-like malformations resulting from faulty development in an organ) polyps in the small bowel and colon. Mutation of the STK11 gene on chromosome 19 has been found in a proportion of patients. The risk of pancreatic adenocarcinoma is significant. Regular colonic surveillance should be performed and female patients should attend breast and cervical screening. Despite the increased risk of malignancy in general, malignant change in the polyps themselves is uncommon. Resection may be indicated, however, for heavy and persistent or recurrent bleeding or intussusception. Polyps may be removed by enterotomy (snared via a colonoscope introduced via an enterotomy) or, by laparotomy. Heavily involved segments of the small intestine may occasionally be resected.</li><li>➤ This is an autosomal dominant condition characterized by melanosis of the mouth and lips , with multiple hamartomatous (benign tumour-like malformations resulting from faulty development in an organ) polyps in the small bowel and colon.</li><li>➤ This is an autosomal dominant condition characterized by melanosis of the mouth and lips , with multiple hamartomatous (benign tumour-like malformations resulting from faulty development in an organ) polyps in the small bowel and colon.</li><li>➤ autosomal dominant</li><li>➤ melanosis of the mouth and lips</li><li>➤ multiple hamartomatous</li><li>➤ polyps in the small bowel and colon.</li><li>➤ Mutation of the STK11 gene on chromosome 19 has been found in a proportion of patients. The risk of pancreatic adenocarcinoma is significant.</li><li>➤ Mutation of the STK11 gene on chromosome 19 has been found in a proportion of patients. The risk of pancreatic adenocarcinoma is significant.</li><li>➤ Regular colonic surveillance should be performed and female patients should attend breast and cervical screening.</li><li>➤ Regular colonic surveillance should be performed and female patients should attend breast and cervical screening.</li><li>➤ Despite the increased risk of malignancy in general, malignant change in the polyps themselves is uncommon.</li><li>➤ Despite the increased risk of malignancy in general, malignant change in the polyps themselves is uncommon.</li><li>➤ Despite the increased risk of malignancy in general, malignant change in the polyps themselves is uncommon.</li><li>➤ Resection may be indicated, however, for heavy and persistent or recurrent bleeding or intussusception. Polyps may be removed by enterotomy (snared via a colonoscope introduced via an enterotomy) or, by laparotomy. Heavily involved segments of the small intestine may occasionally be resected.</li><li>➤ Resection may be indicated, however, for heavy and persistent or recurrent bleeding or intussusception. Polyps may be removed by enterotomy (snared via a colonoscope introduced via an enterotomy) or, by laparotomy. Heavily involved segments of the small intestine may occasionally be resected.</li><li>➤ Ref : Bailey and Love, 28th Ed. Pg. 1309</li><li>➤ Ref : Bailey and Love, 28th Ed. Pg. 1309</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the incorrect statement concerning entero-cutaneous fistulae?", "options": [{"label": "A", "text": "Most commonly results due to a leak from anastomosis", "correct": false}, {"label": "B", "text": "Fistula of &gt; 500ml effluent/day outputs usually heal spontaneously", "correct": true}, {"label": "C", "text": "Nutritional support and skin protection form important constituents of management", "correct": false}, {"label": "D", "text": "Contrast studies are done to define fistula length for reconstruction", "correct": false}], "correct_answer": "B. Fistula of > 500ml effluent/day outputs usually heal spontaneously", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Fistulas of &gt; 500ml effluent/day outputs usually heal spontaneously</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A : True , enterocutaneous fistulas often result from leaks at surgical anastomosis sites.</li><li>• Option A</li><li>• True</li><li>• Option C : True , nutritional support and skin protection are vital components of enterocutaneous fistula management to optimize healing and prevent complications.</li><li>• Option C</li><li>• True</li><li>• Option D : True , contrast studies such as fistulography or computed tomography (CT) are commonly used to define the anatomy and length of the fistula for surgical planning.</li><li>• Option D</li><li>• True</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Low output fistulas of &lt;500ml effluent/day heal spontaneously.</li><li>➤ Low output fistulas of &lt;500ml effluent/day heal spontaneously.</li><li>➤ Principles Of Management of Enterocutaneous Fistulae (SNAP):</li><li>➤ Management of Enterocutaneous Fistulae</li><li>➤ S : Elimination of Sepsis and Skin protection</li><li>➤ S</li><li>➤ N : Nutrition – A period of Parenteral Nutrition may well Be required</li><li>➤ N</li><li>➤ A : Anatomical Assessment</li><li>➤ A</li><li>➤ P : Definitive Planned surgery</li><li>➤ P</li><li>➤ Ref : Bailey and Love, 28th Ed. pg 1315-16</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28th Ed. pg 1315-16</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Carcinoid tumor is diagnosed by which of the following marker?", "options": [{"label": "A", "text": "Urinary 5-HIAA", "correct": true}, {"label": "B", "text": "Serum Chromogranin A", "correct": false}, {"label": "C", "text": "Plasma neuro- specific enolase", "correct": false}, {"label": "D", "text": "Urinary 5- HTP", "correct": false}], "correct_answer": "A. Urinary 5-HIAA", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Urinary 5-HIAA</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option B : Serum chromogranin A levels may be elevated in carcinoid tumors , but it is not typically used for diagnosis.</li><li>• Option B</li><li>• Serum chromogranin A levels</li><li>• elevated in carcinoid tumors</li><li>• Option C : Plasma neuro-specific enolase levels may be elevated in certain neuroendocrine tumors, but it is not specific for carcinoid tumors.</li><li>• Option C</li><li>• Plasma neuro-specific enolase levels</li><li>• elevated</li><li>• Option D : Urinary 5-hydroxytryptophan (5-HTP) levels are not commonly used in the diagnosis of carcinoid tumors.</li><li>• Option D</li><li>• Urinary 5-hydroxytryptophan</li><li>• not commonly used</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The diagnosis of carcinoid tumors often involves measuring urinary 5-hydroxyindoleacetic acid (5-HIAA), a metabolite of serotonin.</li><li>➤ carcinoid tumors</li><li>➤ measuring urinary 5-hydroxyindoleacetic acid</li><li>➤ metabolite of serotonin.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg. 910-911</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg. 910-911</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All are features of carcinoid syndrome except?", "options": [{"label": "A", "text": "Mitral regurgitation", "correct": true}, {"label": "B", "text": "Asthmatic attacks", "correct": false}, {"label": "C", "text": "Reddish blue cyanosis", "correct": false}, {"label": "D", "text": "Diarrhea", "correct": false}], "correct_answer": "A. Mitral regurgitation", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Mitral regurgitation</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option B : Asthmatic attacks can occur in carcinoid syndrome due to bronchoconstriction and airway inflammation.</li><li>• Option B</li><li>• Asthmatic attacks</li><li>• carcinoid syndrome</li><li>• bronchoconstriction</li><li>• Option C : Reddish-blue cyanosis is a common presentation in carcinoid syndrome , often resulting from flushing and peripheral vasoconstriction.</li><li>• Option C</li><li>• Reddish-blue cyanosis</li><li>• presentation in carcinoid syndrome</li><li>• Option D : Diarrhea is a hallmark symptom of carcinoid syndrome , typically resulting from the release of serotonin and other vasoactive substances.</li><li>• Option D</li><li>• Diarrhea</li><li>• hallmark symptom of carcinoid syndrome</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Tricuspid regurgitation and not mitral regurgitation are a feature of carcinoid syndrome . The clinical syndrome itself consists of reddish-blue cyanosis, flushing attacks, diarrhoea, borborygmi, asthmatic attacks and, eventually, pulmonary and tricuspid stenosis. Classically, the flushing attacks are induced by alcohol.</li><li>➤ Tricuspid regurgitation and not mitral regurgitation are a feature of carcinoid syndrome .</li><li>➤ Tricuspid regurgitation</li><li>➤ not mitral regurgitation</li><li>➤ The clinical syndrome itself consists of reddish-blue cyanosis, flushing attacks, diarrhoea, borborygmi, asthmatic attacks and, eventually, pulmonary and tricuspid stenosis. Classically, the flushing attacks are induced by alcohol.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1310</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1310</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 22-year-old female patient presented to the OPD with bouts of abdominal pain and mild diarrhea. On examination, a tender mass was felt at the right iliac fossa. The following radiograph was obtained. What is your probable diagnosis?", "options": [{"label": "A", "text": "Ulcerative colitis", "correct": false}, {"label": "B", "text": "Crohn’s disease", "correct": true}, {"label": "C", "text": "Paralytic ileus", "correct": false}, {"label": "D", "text": "Mesenteric ischemia", "correct": false}], "correct_answer": "B. Crohn’s disease", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/10/picture8_eqsg3VO.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B) Crohn’s disease</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A : Ulcerative colitis typically presents with diffuse colonic inflammation and features such as bloody diarrhea, rectal urgency, and tenesmus. It does not commonly manifest with a tender mass in the right iliac fossa.</li><li>• Option A</li><li>• Ulcerative colitis</li><li>• diffuse colonic inflammation</li><li>• bloody diarrhea, rectal urgency, and tenesmus.</li><li>• Option C : Paralytic ileus is characterized by non-mechanical obstruction of the bowel due to impaired peristalsis , typically seen after abdominal surgery or in response to metabolic disturbances. It does not typically present with a palpable mass in the right iliac fossa.</li><li>• Option C</li><li>• Paralytic ileus</li><li>• non-mechanical obstruction</li><li>• bowel due to impaired peristalsis</li><li>• after abdominal surgery</li><li>• Option D : Mesenteric ischemia presents with severe abdominal pain out of proportion to physical examination findings , often accompanied by systemic symptoms such as fever and leucocytosis. It does not commonly present with a palpable mass in the right iliac fossa.</li><li>• Option D</li><li>• Mesenteric ischemia</li><li>• severe abdominal pain out of proportion to physical examination findings</li><li>• systemic symptoms such as fever and leucocytosis.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Crohn's disease commonly presents with recurrent abdominal pain , diarrhea , and weight loss . Magnetic resonance enterography (oral contrast) or enteroclysis (contrast administered via nasoduodenal tube) is particularly effective at demonstrating small bowel stricturing , including the string sign of Kantor . String of Kantor is not diagnostic of Crohn’s since it is non-specific, it is also seen in Ileocecal TB.</li><li>➤ Crohn's disease commonly presents with recurrent abdominal pain , diarrhea , and weight loss .</li><li>➤ Crohn's disease</li><li>➤ presents with recurrent abdominal pain</li><li>➤ diarrhea</li><li>➤ weight loss</li><li>➤ Magnetic resonance enterography (oral contrast) or enteroclysis (contrast administered via nasoduodenal tube) is particularly effective at demonstrating small bowel stricturing , including the string sign of Kantor . String of Kantor is not diagnostic of Crohn’s since it is non-specific, it is also seen in Ileocecal TB.</li><li>➤ Magnetic resonance enterography</li><li>➤ enteroclysis</li><li>➤ effective at demonstrating small bowel stricturing</li><li>➤ string sign of Kantor</li><li>➤ Ref : Pg 1330 Bailey and Love, 28th Ed.</li><li>➤ Ref</li><li>➤ : Pg 1330 Bailey and Love, 28th Ed.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 4-year-old child presents to the emergency department with a 1-day history of abdominal pain. The pain was initially periumbilical and has now localized to the right lower quadrant. There is associated anorexia and a low-grade fever. On examination, the child appears uncomfortable and has tenderness at McBurney's point. An ultrasound of the abdomen is ordered, suspecting appendicitis. What is the most common location of appendix?", "options": [{"label": "A", "text": "Retrocecal", "correct": true}, {"label": "B", "text": "Subcecal", "correct": false}, {"label": "C", "text": "Pelvic", "correct": false}, {"label": "D", "text": "Pre-ileal", "correct": false}], "correct_answer": "A. Retrocecal", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/28/picture1_qGHdzDS.jpg"], "explanation": "<p><strong>Ans. A) Retrocecal</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option B: Subcecal - The subcecal position is less common and occurs when the appendix is found beneath the cecum . This position can be associated with atypical presentations of appendicitis due to the altered anatomical location.</li><li>• Option B: Subcecal -</li><li>• subcecal position</li><li>• less common</li><li>• occurs when the appendix is found beneath the cecum</li><li>• Option C: Pelvic - When the appendix lies in the pelvis , it is termed pelvic appendix . While it is a recognized position, it is not the most common location. Pelvic appendicitis can present with urinary symptoms due to irritation of the bladder.</li><li>• Option C: Pelvic -</li><li>• appendix lies in the pelvis</li><li>• termed pelvic appendix</li><li>• Option D: Pre-ileal - A pre-ileal position of the appendix is relatively rare compared to the retrocecal position. It is placed in front of the terminal ileum and may also lead to atypical symptoms.</li><li>• Option D: Pre-ileal -</li><li>• pre-ileal position</li><li>• appendix</li><li>• rare compared to the retrocecal position.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Retrocecal position is the most common anatomical location of the appendix , resulting from the differential growth of the cecum and rotation during childhood.</li><li>➤ Retrocecal position</li><li>➤ most common anatomical location of the appendix</li><li>➤ differential growth of the cecum</li><li>➤ rotation during childhood.</li><li>➤ Common locations: Retrocecal (74%) &gt; Pelvic (21%)</li><li>➤ Common locations: Retrocecal (74%) &gt; Pelvic (21%)</li><li>➤ Ref: 28 th Bailey and Love, ed 1335</li><li>➤ Ref:</li><li>➤ 28 th Bailey and Love, ed 1335</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old female with a history of right lower quadrant pain underwent an appendectomy. Histopathological examination of the surgical specimen revealed a tumor at the tip of the appendix. The most common neoplasm of the appendix is?", "options": [{"label": "A", "text": "Adenocarcinoma", "correct": false}, {"label": "B", "text": "Carcinoid", "correct": true}, {"label": "C", "text": "Squamous cell carcinoma", "correct": false}, {"label": "D", "text": "Mucinous cystadenoma", "correct": false}], "correct_answer": "B. Carcinoid", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: Adenocarcinoma - While adenocarcinomas can occur in the appendix , they are quite rare and account for only about 10% of appendiceal tumors.</li><li>• Option A: Adenocarcinoma -</li><li>• occur in the appendix</li><li>• quite rare</li><li>• about 10% of appendiceal tumors.</li><li>• Option C: Squamous cell carcinoma - Squamous cell carcinoma is extremely rare in the appendix and is not commonly found in appendectomy specimens.</li><li>• Option C: Squamous cell carcinoma -</li><li>• extremely rare</li><li>• appendix</li><li>• Option D: Mucinous cystadenoma - Mucinous cystadenomas are a type of tumor found in the appendix, but they are not as common as carcinoid tumors.</li><li>• Option D: Mucinous cystadenoma -</li><li>• type of tumor found in the appendix,</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Carcinoid tumors are the most common neoplasm found in the appendix , occurring in 0.3 to 0.9% of appendectomy specimens.</li><li>➤ Carcinoid tumors</li><li>➤ most common neoplasm found in the appendix</li><li>➤ 0.3 to 0.9% of appendectomy specimens.</li><li>➤ Ref: Bailey and Love 28 th Ed. Pg 1349, Sabiston 21 st Ed. Pg 1315.</li><li>➤ Ref:</li><li>➤ Bailey and Love 28 th Ed. Pg 1349, Sabiston 21 st Ed. Pg 1315.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is not true regarding the etiology of acute appendicitis?", "options": [{"label": "A", "text": "The common organisms implicated in appendicitis are anaerobic in nature", "correct": true}, {"label": "B", "text": "Luminal obstruction is the initiating event in acute appendicitis", "correct": false}, {"label": "C", "text": "Increased consumption of refined carbohydrates is implicated in acute appendicitis", "correct": false}, {"label": "D", "text": "Enterobius vermicularis , can proliferate in the appendix and occlude the lumen", "correct": false}], "correct_answer": "A. The common organisms implicated in appendicitis are anaerobic in nature", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option B: Obstruction of the appendix lumen has been implicated as the initiating event and some form of luminal obstruction , either by a fecolith or by a stricture, is found in the majority of cases.</li><li>• Option B:</li><li>• Obstruction of the appendix lumen</li><li>• implicated as the initiating event</li><li>• some form of luminal obstruction</li><li>• A fecolith (sometimes referred to as an appendicolith) is composed of inspissated faecal material , calcium phosphates , bacteria and epithelial debris , which leads to the buildup of mucus secretions and air due to bacteria. With progressive dilation, venous drainage may get hampered, leading to full-thickness ischemia and perforation.</li><li>• fecolith</li><li>• composed of inspissated faecal material</li><li>• calcium phosphates</li><li>• bacteria</li><li>• epithelial debris</li><li>• buildup of mucus secretions</li><li>• air due to bacteria.</li><li>• Mechanism: Obstructed lumen of appendix → Retained secretions with distension of lumen → Secretions get infected → Venous occlusion due to increased pressure → Bacterial translocation → Gangrene &amp; perforation → Appendicular abscess</li><li>• Mechanism: Obstructed lumen of appendix → Retained secretions with distension of lumen → Secretions get infected → Venous occlusion due to increased pressure → Bacterial translocation → Gangrene &amp; perforation → Appendicular abscess</li><li>• Option C: Decreased dietary fiber and increased consumption of refined carbohydrates may be an important cause . In resource-poor countries that are adopting a more refined Western-type diet, the incidence continues to rise.</li><li>• Option C:</li><li>• Decreased dietary fiber and increased consumption of refined carbohydrates may be an important cause</li><li>• Option D: Intestinal parasites , particularly Enterobius vermicularis (pinworm), can proliferate in the appendix and occlude the lumen.</li><li>• Option D:</li><li>• Intestinal parasites</li><li>• Enterobius vermicularis</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• The common organism implicated in appendicitis are a mixed growth of aerobic and anaerobic organisms.</li><li>• common organism implicated in appendicitis</li><li>• mixed growth of aerobic and anaerobic organisms.</li><li>• Ref: Bailey and Love 28 th ed. Pg 1337.</li><li>• Ref: Bailey and Love 28 th ed. Pg 1337.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 72-year-old male with a history of rheumatoid arthritis treated with methotrexate presents to the emergency department with a 2-day history of progressively worsening abdominal pain, now localized to the right lower quadrant. He has a low-grade fever and mild leukocytosis. A CT scan of the abdomen suggests appendicitis without abscess or mass effect. All of the following are risk factors for perforation of appendix except?", "options": [{"label": "A", "text": "Fecolith obstruction", "correct": false}, {"label": "B", "text": "Retrocaecal appendix", "correct": true}, {"label": "C", "text": "Immunosuppression", "correct": false}, {"label": "D", "text": "Very old patient", "correct": false}], "correct_answer": "B. Retrocaecal appendix", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: Fecolith obstruction - A fecolith can obstruct the appendiceal lumen , leading to increased intraluminal pressure , ischemia , and eventually perforation , thus it is a risk factor for appendiceal perforation.</li><li>• Option A:</li><li>• Fecolith obstruction -</li><li>• fecolith can obstruct the appendiceal lumen</li><li>• increased intraluminal pressure</li><li>• ischemia</li><li>• eventually perforation</li><li>• Option C: Immunosuppression - Immunosuppressed patients, such as those on medications like methotrexate for rheumatoid arthritis , are at higher risk for perforation due to a potentially blunted immune response that can delay diagnosis and treatment.</li><li>• Option C: Immunosuppression -</li><li>• those on medications like methotrexate for rheumatoid arthritis</li><li>• higher risk for perforation</li><li>• Option D: Advanced age - Older patients are at a higher risk for perforation , possibly due to delayed presentation and diagnosis, as well as the presence of comorbid conditions that can complicate the course of appendicitis.</li><li>• Option D: Advanced age -</li><li>• Older patients</li><li>• higher risk for perforation</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The retrocecal position of the appendix is not a risk factor for its perforation. Risk factors for perforation include fecolith obstruction , immunosuppression , extremes of age , previous abdominal surgery , a pelvic position of the appendix , diabetes mellitus, and others, but not the retrocecal position itself.</li><li>➤ retrocecal position of the appendix</li><li>➤ not a risk factor for its perforation.</li><li>➤ Risk factors</li><li>➤ perforation include fecolith obstruction</li><li>➤ immunosuppression</li><li>➤ extremes of age</li><li>➤ previous abdominal surgery</li><li>➤ pelvic position of the appendix</li><li>➤ Ref: Bailey and Love 28 th ed. Pg 1338.</li><li>➤ Ref: Bailey and Love 28 th ed. Pg 1338.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Match the following signs seen in acute appendicitis with their named counterparts.", "options": [{"label": "A", "text": "1-d, 2-a, 3-b, 4-c", "correct": false}, {"label": "B", "text": "1-b, 2-a, 3-d, 4-c", "correct": true}, {"label": "C", "text": "1-b, 2-d, 3-c,4-a", "correct": false}, {"label": "D", "text": "1-d, 2-c, 3-a, 4-b", "correct": false}], "correct_answer": "B. 1-b, 2-a, 3-d, 4-c", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/28/picture4_NMbZ3iP.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/28/picture5_VQQfmNA.jpg"], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Blumberg sign: Gentle superficial palpation of the abdomen , beginning in the left iliac fossa and moving anticlockwise to the right iliac fossa , will detect muscle guarding over the point of maximum tenderness , classically McBurney’s point . Asking the patient to cough or gentle percussion over the site of maximum tenderness will elicit rebound tenderness .</li><li>• Blumberg sign:</li><li>• Gentle superficial palpation</li><li>• abdomen</li><li>• beginning in the left iliac fossa</li><li>• anticlockwise to the right iliac fossa</li><li>• muscle guarding over the point of maximum tenderness</li><li>• McBurney’s point</li><li>• rebound tenderness</li><li>• Rovsing’s sign : On pressing the left iliac fossa , pain is elicited in right iliac fossa</li><li>• Rovsing’s sign</li><li>• left iliac fossa</li><li>• pain is elicited in right iliac fossa</li><li>• Psoas sign: Occasionally, an inflamed appendix lies on the psoas muscle , and the patient, often a young adult , will lie with the right hip flexed for pain relief (the psoas sign) . On extension of the hip, he experiences pain in RIF.</li><li>• Psoas sign:</li><li>• inflamed appendix</li><li>• lies on the psoas muscle</li><li>• young adult</li><li>• right hip flexed for pain relief</li><li>• (the psoas sign)</li><li>• Obturator sign: Spasm of the obturator internus is sometimes demonstrable when the hip is flexed and internally rotated . If an inflamed appendix is in contact with the obturator internus, this manoeuvre will cause pain in the hypogastrium (the obturator test; Zachary Cope).</li><li>• Obturator sign:</li><li>• Spasm of the obturator internus</li><li>• hip is flexed and internally rotated</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Ref: Bailey and Love 28 th Ed. Pg 1339</li><li>• Ref:</li><li>• Bailey and Love 28 th Ed. Pg 1339</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 10 years old girl is brought to the casualty with a history of abdominal pain and vomiting for the past 4 hours. On examination, the patient has pyrexia and there is tenderness and rebound tenderness in the right iliac fossa. Which among the following is the preferred imaging modality in this patient?", "options": [{"label": "A", "text": "CT scan", "correct": false}, {"label": "B", "text": "Ultrasound of the abdomen", "correct": true}, {"label": "C", "text": "MRI", "correct": false}, {"label": "D", "text": "X-ray", "correct": false}], "correct_answer": "B. Ultrasound of the abdomen", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B. Ultrasound of the abdomen</strong></p>\n<p><strong>References:</strong></p><ul><li>↳ Reference: Bailey and Love, 28 th Ed. Pg 1342</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 30-year-old male presents to the emergency department with a three-day history of right lower quadrant (RLQ) abdominal pain, fever, and nausea. A computed tomography (CT) scan reveals a 5 cm appendiceal mass without evidence of perforation or abscess formation, with adhered omentum (phlegmon). The patient's vital signs are stable, and he reports that the pain has not worsened over the past 24 hours. What is the management of this condition?", "options": [{"label": "A", "text": "Conservative management", "correct": true}, {"label": "B", "text": "Emergency open appendicectomy", "correct": false}, {"label": "C", "text": "Emergency laparoscopic appendicectomy", "correct": false}, {"label": "D", "text": "Limited ileo-colic resection", "correct": false}], "correct_answer": "A. Conservative management", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Conservative management</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• If an appendix mass (phlegmon) is present and the patient's condition is satisfactory , the standard treatment is the conservative Ochsner-Sherren regime .</li><li>• appendix mass</li><li>• present and the patient's condition is satisfactory</li><li>• standard treatment is the conservative Ochsner-Sherren regime</li><li>• The Oshner-Sherren regimen includes:</li><li>• The Oshner-Sherren regimen includes:</li><li>• Fasting (nil by mouth) IV Fluids Hot fomentation Fowler’s position IV antibiotics Monitoring the size of lump</li><li>• Fasting (nil by mouth)</li><li>• Fasting (nil by mouth)</li><li>• IV Fluids</li><li>• IV Fluids</li><li>• Hot fomentation</li><li>• Hot fomentation</li><li>• Fowler’s position</li><li>• Fowler’s position</li><li>• IV antibiotics</li><li>• IV antibiotics</li><li>• Monitoring the size of lump</li><li>• Monitoring the size of lump</li><li>• Criteria for stopping conservative treatment of an appendix mass</li><li>• Criteria for stopping conservative treatment of an appendix mass</li><li>• A rising pulse rate. Increasing or spreading abdominal pain Increasing size of the mass.</li><li>• A rising pulse rate.</li><li>• A rising pulse rate.</li><li>• Increasing or spreading abdominal pain</li><li>• Increasing or spreading abdominal pain</li><li>• Increasing size of the mass.</li><li>• Increasing size of the mass.</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Conservative management is considered in cases where an appendiceal mass/phlegmonous appendicitis is present , the patient's condition is stable , and there is no sign of complications , such as perforation or abscess.</li><li>• Conservative management</li><li>• appendiceal mass/phlegmonous appendicitis is present</li><li>• stable</li><li>• no sign of complications</li><li>• perforation or abscess.</li><li>• Ref : Bailey and Love 28 th Ed. Pg 1343</li><li>• Ref : Bailey and Love 28 th Ed. Pg 1343</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "25 years old male presents with low grade fever and RIF tenderness. USG reveals dilated appendix with peri-appendiceal free fluid. On exploration via McArthur’s incision, an appendicular phlegmon is found. What will be the next step?", "options": [{"label": "A", "text": "Complete the appendicectomy", "correct": false}, {"label": "B", "text": "Drain the collection without performing appendicectomy", "correct": true}, {"label": "C", "text": "Limited right hemicolectomy", "correct": false}, {"label": "D", "text": "Abandon the procedure and perform a proximal ileostomy", "correct": false}], "correct_answer": "B. Drain the collection without performing appendicectomy", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Drain the collection without performing appendicectomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: Complete the appendicectomy - Normally indicated for appendicitis , but if a phlegmon is present , attempting to remove the appendix may increase the risk of complications.</li><li>• Option A: Complete the appendicectomy -</li><li>• indicated for appendicitis</li><li>• phlegmon is present</li><li>• Option C: Limited right hemicolectomy - This procedure is more extensive and typically reserved for cases with a suspicion of malignancy.</li><li>• Option C: Limited right hemicolectomy -</li><li>• more extensive</li><li>• reserved for cases</li><li>• suspicion of malignancy.</li><li>• Option D: Abandon the procedure and perform a proximal ileostomy - While this might be a safe option in some cases to avoid further complications, a proximal ileostomy is not indicated here.</li><li>• Option D: Abandon the procedure and perform a proximal ileostomy -</li><li>• might be a safe option</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In the presence of an appendicular phlegmon , it is safer to drain the collection and manage with antibiotics rather than performing an appendicectomy, which could increase the risk of bowel injury .</li><li>➤ presence of an appendicular phlegmon</li><li>➤ safer to drain the collection and manage with antibiotics</li><li>➤ performing an appendicectomy,</li><li>➤ increase the risk of bowel injury</li><li>➤ Special situations during appendicectomy:</li><li>➤ Special situations during appendicectomy:</li><li>➤ The finding of a normal appendix demands careful exclusion of other possible diagnoses, particularly terminal ileitis, Meckel’s diverticulitis and tubal or ovarian causes in women. It is usual to remove the appendix to avoid future diagnostic difficulties, even though the appendix is macroscopically normal. If an appendix mass is found at operation, particularly at laparoscopy, it may be safer to abandon the procedure rather than risk bowel injury during attempted mobilisation. Any abscess should be drained, intravenous antibiotics administered and the patient carefully monitored during the postoperative period. Very rarely in the face of a frankly necrotic appendix, a colectomy or partial right hemicolectomy is required. Crohn's disease - If caecum is healthy- appendectomy If cecum involved - avoid appendectomy</li><li>➤ The finding of a normal appendix demands careful exclusion of other possible diagnoses, particularly terminal ileitis, Meckel’s diverticulitis and tubal or ovarian causes in women. It is usual to remove the appendix to avoid future diagnostic difficulties, even though the appendix is macroscopically normal.</li><li>➤ The finding of a normal appendix demands careful exclusion of other possible diagnoses, particularly terminal ileitis, Meckel’s diverticulitis and tubal or ovarian causes in women. It is usual to remove the appendix to avoid future diagnostic difficulties, even though the appendix is macroscopically normal.</li><li>➤ If an appendix mass is found at operation, particularly at laparoscopy, it may be safer to abandon the procedure rather than risk bowel injury during attempted mobilisation. Any abscess should be drained, intravenous antibiotics administered and the patient carefully monitored during the postoperative period. Very rarely in the face of a frankly necrotic appendix, a colectomy or partial right hemicolectomy is required.</li><li>➤ If an appendix mass is found at operation, particularly at laparoscopy, it may be safer to abandon the procedure rather than risk bowel injury during attempted mobilisation. Any abscess should be drained, intravenous antibiotics administered and the patient carefully monitored during the postoperative period. Very rarely in the face of a frankly necrotic appendix, a colectomy or partial right hemicolectomy is required.</li><li>➤ Crohn's disease - If caecum is healthy- appendectomy</li><li>➤ Crohn's disease - If caecum is healthy- appendectomy</li><li>➤ Crohn's disease -</li><li>➤ If cecum involved - avoid appendectomy</li><li>➤ If cecum involved - avoid appendectomy</li><li>➤ -</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 1346</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 1346</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the incorrect statement concerning Meckel’s diverticulum.", "options": [{"label": "A", "text": "It’s a persistent remnant of the Vitello-intestinal duct", "correct": false}, {"label": "B", "text": "It is a false diverticulum", "correct": true}, {"label": "C", "text": "It may contain heterotopic pancreatic mucosa", "correct": false}, {"label": "D", "text": "Can present as diverticulitis", "correct": false}], "correct_answer": "B. It is a false diverticulum", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) It is a false diverticulum.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: This is correct. Meckel’s diverticulum is indeed a remnant of the vitello-intestinal duct, which normally obliterates during embryonic development.</li><li>• Option A: This is correct.</li><li>• Option C: This is correct. Meckel’s diverticulum can contain heterotopic tissue, most commonly gastric and sometimes pancreatic.</li><li>• Option C: This is correct.</li><li>• Option D: This is correct. Meckel’s diverticulum can present with symptoms of diverticulitis, similar to those of appendicitis, or with bleeding due to ulceration caused by ectopic gastric mucosa.</li><li>• Option D: This is correct.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Meckel’s diverticulum is a true congenital diverticulum , which contains all layers of the intestinal wall and can present with complications like acquired diverticulitis.</li><li>➤ Meckel’s diverticulum</li><li>➤ true congenital diverticulum</li><li>➤ all layers of the intestinal wall</li><li>➤ present with complications like acquired diverticulitis.</li><li>➤ It is a remnant of the Vitello-intestinal Duct , on the antimesenteric side of the ileum. It is approx. 2 feet from the ileo-caecal valve and approx. 2 inches long Sometimes, the mucosa of a Meckel’s diverticulum contains heterotopic epithelium of gastric, colonic or pancreatic type Can present clinically as: Hemorrhage in children due to ectopic gastric mucosa leading to ileal ulcers Diverticulitis Intussusception Intestinal obstruction due to bands/volvulus- in adults Perforation Treatment: Meckel’s diverticulectomy/ileal resection and anastomosis When found in the course of abdominal surgery, a Meckel's diverticulum can safely be left alone, provided it has a wide mouth and is not thickened. When there is doubt, it can be resected.</li><li>➤ It is a remnant of the Vitello-intestinal Duct , on the antimesenteric side of the ileum.</li><li>➤ It is a remnant of the Vitello-intestinal Duct , on the antimesenteric side of the ileum.</li><li>➤ remnant of the Vitello-intestinal Duct</li><li>➤ It is approx. 2 feet from the ileo-caecal valve and approx. 2 inches long</li><li>➤ It is approx. 2 feet from the ileo-caecal valve and approx. 2 inches long</li><li>➤ 2 feet</li><li>➤ 2 inches</li><li>➤ Sometimes, the mucosa of a Meckel’s diverticulum contains heterotopic epithelium of gastric, colonic or pancreatic type</li><li>➤ Sometimes, the mucosa of a Meckel’s diverticulum contains heterotopic epithelium of gastric, colonic or pancreatic type</li><li>➤ Can present clinically as: Hemorrhage in children due to ectopic gastric mucosa leading to ileal ulcers Diverticulitis Intussusception Intestinal obstruction due to bands/volvulus- in adults Perforation Treatment: Meckel’s diverticulectomy/ileal resection and anastomosis When found in the course of abdominal surgery, a Meckel's diverticulum can safely be left alone, provided it has a wide mouth and is not thickened. When there is doubt, it can be resected.</li><li>➤ Can present clinically as:</li><li>➤ Can present clinically as:</li><li>➤ Hemorrhage in children due to ectopic gastric mucosa leading to ileal ulcers Diverticulitis Intussusception Intestinal obstruction due to bands/volvulus- in adults Perforation Treatment: Meckel’s diverticulectomy/ileal resection and anastomosis When found in the course of abdominal surgery, a Meckel's diverticulum can safely be left alone, provided it has a wide mouth and is not thickened. When there is doubt, it can be resected.</li><li>➤ Hemorrhage in children due to ectopic gastric mucosa leading to ileal ulcers</li><li>➤ Hemorrhage in children due to ectopic gastric mucosa leading to ileal ulcers</li><li>➤ Diverticulitis</li><li>➤ Diverticulitis</li><li>➤ Intussusception</li><li>➤ Intussusception</li><li>➤ Intestinal obstruction due to bands/volvulus- in adults</li><li>➤ Intestinal obstruction due to bands/volvulus- in adults</li><li>➤ Perforation</li><li>➤ Perforation</li><li>➤ Treatment: Meckel’s diverticulectomy/ileal resection and anastomosis</li><li>➤ Treatment: Meckel’s diverticulectomy/ileal resection and anastomosis</li><li>➤ Treatment:</li><li>➤ When found in the course of abdominal surgery, a Meckel's diverticulum can safely be left alone, provided it has a wide mouth and is not thickened. When there is doubt, it can be resected.</li><li>➤ When found in the course of abdominal surgery, a Meckel's diverticulum can safely be left alone, provided it has a wide mouth and is not thickened. When there is doubt, it can be resected.</li><li>➤ Ref: Bailey and Love 28 th ed. Pg. 1311- 1312</li><li>➤ Ref: Bailey and Love 28 th ed. Pg. 1311- 1312</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 4-year-old boy presents with a significant history of bleeding per rectum and severe anemia. The diagnostic investigation reveals uptake in the area of the small intestine consistent with the presence of ectopic gastric tissue. What is the most appropriate treatment for this condition?", "options": [{"label": "A", "text": "Blood transfusion", "correct": false}, {"label": "B", "text": "Endoscopic intervention", "correct": false}, {"label": "C", "text": "Chemotherapy", "correct": false}, {"label": "D", "text": "Excision", "correct": true}], "correct_answer": "D. Excision", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/28/picture9_rRKTW4e.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: While blood transfusion is important for addressing the acute anemia , it does not treat the underlying cause of the bleeding.</li><li>• Option A:</li><li>• blood transfusion</li><li>• addressing the acute anemia</li><li>• Option B: Endoscopic intervention may not be feasible in small children and may not provide a definitive treatment if a Meckel's diverticulum is the bleeding source.</li><li>• Option B:</li><li>• Endoscopic intervention</li><li>• feasible in small children</li><li>• Option C: Chemotherapy is not used in the treatment of Meckel's diverticulum.</li><li>• Option C:</li><li>• Chemotherapy</li><li>• not used in the treatment of Meckel's diverticulum.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective –</li><li>➤ To treat complicated Meckel's diverticulum with bleeding , excision of the diverticulum is the definitive treatment to remove the ectopic gastric mucosa and resolve the bleeding.</li><li>➤ treat complicated Meckel's diverticulum with bleeding</li><li>➤ excision of the diverticulum</li><li>➤ definitive treatment to remove the ectopic gastric mucosa</li><li>➤ resolve the bleeding.</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 261</li><li>➤ Ref:</li><li>➤ Bailey and Love, 28 th Ed. Pg 261</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the correct statement concerning intestinal diverticula.", "options": [{"label": "A", "text": "In congenital diverticulum, only the mucosa of the small bowel is present in the wall of the diverticula", "correct": false}, {"label": "B", "text": "Acquired diverticula often arise from the mesenteric side of the bowel", "correct": true}, {"label": "C", "text": "Bleeding is a very common complication", "correct": false}, {"label": "D", "text": "Ileum is the most commonly affected site for diverticular disease", "correct": false}], "correct_answer": "B. Acquired diverticula often arise from the mesenteric side of the bowel", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: In congenital diverticulum like Meckel’s diverticulum , all 3 coats of bowel are present in the wall of the diverticulum.</li><li>• Option A:</li><li>• Meckel’s diverticulum</li><li>• 3 coats of bowel are present</li><li>• Option C: Bleeding from a jejunal diverticulum is a rare complication , compared with sigmoid diverticular disease.</li><li>• Option C:</li><li>• Bleeding from a jejunal diverticulum</li><li>• rare complication</li><li>• Option D: Duodenum followed by jejunum are more commonly affected.</li><li>• Option D:</li><li>• Duodenum</li><li>• jejunum are more commonly affected.</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Acquired intestinal diverticula often develop in the jejunum , and arise from the mesenteric side of the bowel as a result of mucosal herniation at the point of entry of the blood vessels , where there is a potential defect in the muscularis layer.</li><li>• Acquired intestinal diverticula</li><li>• develop in the jejunum</li><li>• arise from the mesenteric side of the bowel</li><li>• mucosal herniation</li><li>• point of entry of the blood vessels</li><li>• Ref: Bailey and Love, 28 th Ed. Pg 1311</li><li>• Ref: Bailey and Love, 28 th Ed. Pg 1311</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old female presents with abdominal distension. Imaging reveals liver scalloping and omental caking. Intraoperative findings include multiple gelatinous deposits within the peritoneal cavity as shown. What is the most likely diagnosis?", "options": [{"label": "A", "text": "Miliary TB", "correct": false}, {"label": "B", "text": "Pseudomyxoma peritonei", "correct": true}, {"label": "C", "text": "Disseminate hydatid", "correct": false}, {"label": "D", "text": "Gossypiboma", "correct": false}], "correct_answer": "B. Pseudomyxoma peritonei", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/28/picture10_jzKubFl.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: Miliary TB usually presents with multiple granulomas throughout the body , including the peritoneum , but does not typically present with jelly-like cysts or scalloping of the liver.</li><li>• Option A:</li><li>• Miliary TB</li><li>• multiple granulomas</li><li>• throughout the body</li><li>• peritoneum</li><li>• Option C: Disseminated hydatid disease would show cystic structures caused by Echinococcus tapeworm infection , which usually has a different appearance on imaging and during surgery.</li><li>• Option C:</li><li>• Disseminated hydatid disease</li><li>• show cystic structures</li><li>• Echinococcus tapeworm infection</li><li>• Option D: Gossypiboma refers to a retained surgical sponge or cloth after surgery , which can lead to a foreign body reaction but would not typically cause the extensive findings described here.</li><li>• Option D:</li><li>• Gossypiboma refers to a retained surgical sponge</li><li>• cloth after surgery</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Pseudomyxoma peritonei is diagnosed by the presence of jelly-like mucinous deposits in the peritoneal cavity typically originating from a ruptured mucinous tumor of the ovary or appendix.</li><li>➤ Pseudomyxoma peritonei</li><li>➤ presence of jelly-like mucinous deposits</li><li>➤ peritoneal cavity</li><li>➤ originating from a ruptured mucinous tumor</li><li>➤ ovary or appendix.</li><li>➤ Pseudomyxoma peritonei:</li><li>➤ Pseudomyxoma peritonei:</li><li>➤ Usually seen in women Peritoneal cavity studded with yellow jelly like cysts. Believed to occur due to ruptured mucinous cystic tumour of ovary/appendix. Patients typically present with progressive and massive abdominal distension, anorexia and symptoms of bowel dysfunction. Rx: Complete cytoreduction (Sugar baker) = Multivisceral resection of right coIon, GB, spleen, greater and lesser omentum, peritoneal stripping. HIPEC: Hyperthermic Intraoperative chemotherapy (Mitomycin C)</li><li>➤ Usually seen in women</li><li>➤ Peritoneal cavity studded with yellow jelly like cysts.</li><li>➤ Believed to occur due to ruptured mucinous cystic tumour of ovary/appendix.</li><li>➤ Patients typically present with progressive and massive abdominal distension, anorexia and symptoms of bowel dysfunction.</li><li>➤ Rx: Complete cytoreduction (Sugar baker) = Multivisceral resection of right coIon, GB, spleen, greater and lesser omentum, peritoneal stripping.</li><li>➤ Rx:</li><li>➤ HIPEC: Hyperthermic Intraoperative chemotherapy (Mitomycin C)</li><li>➤ HIPEC:</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 1351-52.</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 1351-52.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the incorrect statement concerning the anatomy of the appendix?", "options": [{"label": "A", "text": "The base of the appendix is found at the confluence of the three taeniae coli of the caecum.", "correct": false}, {"label": "B", "text": "The appendicular artery is an end artery", "correct": false}, {"label": "C", "text": "Neuroendocrine tumors of the appendix arise from the mucosal cells present at the base of the crypts", "correct": true}, {"label": "D", "text": "There is usually abundant lymphoid tissue in the sub-mucosa", "correct": false}], "correct_answer": "C. Neuroendocrine tumors of the appendix arise from the mucosal cells present at the base of the crypts", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/28/picture2_6ZcPHTF.jpg"], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: The position of the base of the appendix is constant , being found at the confluence of the three taeniae coli of the caecum , which fuse to form the outer longitudinal muscle coat of the appendix.</li><li>• Option A:</li><li>• position of the base of the appendix is constant</li><li>• confluence of the three taeniae coli</li><li>• caecum</li><li>• Option B: Appendicular artery is an ‘end-artery’ , thrombosis of which results in necrosis of the appendix.</li><li>• Option B:</li><li>• Appendicular artery</li><li>• ‘end-artery’</li><li>• Option D: The submucosa contains numerous lymphatic aggregations or follicles . The prominence of lymphatic tissue in the appendix of young adults seems to be important in the etiology of appendicitis.</li><li>• Option D:</li><li>• submucosa</li><li>• numerous lymphatic aggregations or follicles</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Neuro endocrine tumours (NETS’s) arise from the argentaffin cells (Kulchitsky cells) and not the mucosal cells which are situated at the base of the crypts .</li><li>• Neuro endocrine tumours</li><li>• argentaffin cells</li><li>• not the mucosal cells</li><li>• base of the crypts</li><li>• Ref: Bailey and Love 28 th Ed., Pg 1335, 1336</li><li>• Ref:</li><li>• Bailey and Love 28 th Ed., Pg 1335, 1336</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A child with complaints of lower abdominal pain and nausea is being examined. On deep palpation in the left iliac fossa, the child experiences pain in the right iliac fossa as shown in the image. What is the name of this sign?", "options": [{"label": "A", "text": "Blumberg sign", "correct": false}, {"label": "B", "text": "McBurney’s sign", "correct": false}, {"label": "C", "text": "Rovsing’s sign", "correct": true}, {"label": "D", "text": "Pointing sign", "correct": false}], "correct_answer": "C. Rovsing’s sign", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/28/picture3_QUiMU23.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: Blumberg sign - Also known as rebound tenderness , this sign is positive when pain is felt upon the quick release of deep pressure in the right iliac fossa . This is a general sign of peritoneal irritation, not specific to appendicitis.</li><li>• Option A: Blumberg sign -</li><li>• rebound tenderness</li><li>• sign is positive when pain is felt upon the quick release of deep pressure in the right iliac fossa</li><li>• Option B: McBurney's sign - This is tenderness at McBurney's point , which is located one-third the distance from the anterior superior iliac spine to the umbilicus . This sign is often used to localize pain in appendicitis.</li><li>• Option B: McBurney's sign -</li><li>• tenderness at McBurney's point</li><li>• located one-third the distance</li><li>• anterior superior iliac spine to the umbilicus</li><li>• Option D: Pointing sign - This implies the patient pointing towards the umbilicus as the site of initiation of pain , which later shifts to right iliac fossa.</li><li>• Option D: Pointing sign -</li><li>• pointing towards the umbilicus</li><li>• site of initiation of pain</li><li>• right iliac fossa.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Rovsing's sign is a clinical indicator in the diagnosis of acute appendicitis, characterized by pain in the right lower quadrant elicited by deep palpation of the left lower quadrant.</li><li>➤ Rovsing's sign</li><li>➤ acute appendicitis,</li><li>➤ pain in the right lower quadrant</li><li>➤ deep palpation of the left lower quadrant.</li><li>➤ Ref: Bailey and Love 28th Ed. Pg 1339</li><li>➤ Ref: Bailey and Love 28th Ed. Pg 1339</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 16-year-old male presents to the emergency department with a 10-hour history of abdominal pain that initially started around the umbilicus and has now localized to the right lower quadrant (RIF). The pain is associated with nausea and the patient reports loss of appetite. Physical examination reveals RIF tenderness and a low-grade fever. Laboratory tests show leukocytosis with a left shift. Which of the following parameters from the above-mentioned scoring system is given 2 points?", "options": [{"label": "A", "text": "Anorexia", "correct": false}, {"label": "B", "text": "Rebound tenderness", "correct": false}, {"label": "C", "text": "Tenderness at RIF", "correct": true}, {"label": "D", "text": "Nausea and vomiting", "correct": false}], "correct_answer": "C. Tenderness at RIF", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/28/picture6_8XTtWt6.jpg"], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: Anorexia - While anorexia is part of the Alvarado score , it contributes only one point to the total score .</li><li>• Option A: Anorexia -</li><li>• part of the Alvarado score</li><li>• only one point to the total score</li><li>• Option B: Rebound tenderness - This finding is also included in the Alvarado score but is assigned only one point.</li><li>• Option B: Rebound tenderness -</li><li>• Alvarado score but is assigned only one point.</li><li>• Option D: Nausea and vomiting - These symptoms are common in appendicitis , but in the Alvarado scoring system, they contribute only one point.</li><li>• Option D: Nausea and vomiting -</li><li>• common in appendicitis</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Tenderness in RIF and leucocytosis are given 2 points in Alvarado score.</li><li>➤ Tenderness in RIF and leucocytosis are given 2 points in Alvarado score.</li><li>➤ Alvarado score (MANTRELS)</li><li>➤ Alvarado score (MANTRELS)</li><li>➤ Ref: Bailey and Love 28 th ed, pg 1342</li><li>➤ Ref:</li><li>➤ Bailey and Love 28 th ed, pg 1342</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 19-year-old woman presents to the emergency department with a 24-hour history of abdominal pain, initially periumbilical, now localized to the right lower quadrant. She reports nausea and has vomited twice. She also has a low-grade fever. On examination, there is tenderness and voluntary guarding in the right lower quadrant, but no rigidity. Her laboratory tests show a mild leukocytosis. Murphy’s triad of appendicitis includes the following clinical features except?", "options": [{"label": "A", "text": "Periumbilical pain migrating to RIF", "correct": false}, {"label": "B", "text": "Vomiting", "correct": false}, {"label": "C", "text": "Fever", "correct": false}, {"label": "D", "text": "Muscle guarding and rigidity", "correct": true}], "correct_answer": "D. Muscle guarding and rigidity", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Muscle guarding and rigidity</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Murphy’s triad in acute appendicitis includes:</li><li>• Murphy’s triad in acute appendicitis includes:</li><li>• Pain: Typically, peri umbilical pain which migrates to RIF Vomiting due to severe pain Fever typically, low grade</li><li>• Pain: Typically, peri umbilical pain which migrates to RIF</li><li>• Pain: Typically, peri umbilical pain which migrates to RIF</li><li>• Vomiting due to severe pain</li><li>• Vomiting due to severe pain</li><li>• Fever typically, low grade</li><li>• Fever typically, low grade</li><li>• While muscle guarding may be present in acute appendicitis , rigidity suggests a more severe, generalized peritoneal irritation and is not typically included in Murphy's triad , which focuses on earlier, more specific signs.</li><li>• muscle guarding</li><li>• present in acute appendicitis</li><li>• rigidity</li><li>• severe, generalized peritoneal irritation</li><li>• not typically included in Murphy's triad</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The components of Murphy's triad in acute appendicitis : periumbilical pain that migrates to the right iliac fossa , vomiting , and low-grade fever . Muscle guarding and rigidity are associated with a more advanced stage of inflammation and are not part of the triad.</li><li>➤ components of Murphy's triad</li><li>➤ acute appendicitis</li><li>➤ periumbilical pain</li><li>➤ migrates to the right iliac fossa</li><li>➤ vomiting</li><li>➤ low-grade fever</li><li>➤ Ref : Bailey and Love 28 th Ed., Pg. 1338-39</li><li>➤ Ref : Bailey and Love 28 th Ed., Pg. 1338-39</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A surgeon is preparing to perform an appendectomy on a 30-year-old patient with acute appendicitis. The surgical plan includes making an oblique muscle splitting incision in the right lower quadrant of the abdomen. What is the name of this incision?", "options": [{"label": "A", "text": "Gridiron incision", "correct": true}, {"label": "B", "text": "Lanz incision", "correct": false}, {"label": "C", "text": "Rutherford-Morison incision", "correct": false}, {"label": "D", "text": "Rocky-Davis incision", "correct": false}], "correct_answer": "A. Gridiron incision", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/28/picture7_NdkjCF3.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/Screenshot%202025-02-03%20121407.jpg"], "explanation": "<p><strong>Ans. A) Gridiron incision</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option B: Lanz incision - A Lanz incision is a transverse incision made approximately 2 cm below the umbilicus , centered on the midclavicular-mid inguinal line . It is not oblique but rather a transverse skin crease incision.</li><li>• Option B: Lanz incision -</li><li>• transverse incision made approximately 2 cm below the umbilicus</li><li>• centered on the midclavicular-mid inguinal line</li><li>• Option C: Rutherford-Morison incision - This is an oblique muscle-cutting incision , with its lower end over McBurney's point , extending obliquely upwards and laterally. It is more extensive and not typically used for a straightforward appendectomy.</li><li>• Option C: Rutherford-Morison incision -</li><li>• oblique muscle-cutting incision</li><li>• lower end over McBurney's point</li><li>• Option D: Rocky-Davis incision - A Rocky-Davis incision is a transverse right lower quadrant incision . Although it is used for appendectomies, it does not match the oblique description given.</li><li>• Option D: Rocky-Davis incision -</li><li>• transverse right lower quadrant incision</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Gridiron incision is an oblique muscle-splitting incision in the right lower quadrant used for appendectomy.</li><li>➤ Gridiron incision is an oblique muscle-splitting incision</li><li>➤ right lower quadrant</li><li>➤ appendectomy.</li><li>➤ Lanz incision : Transverse or skin crease incision for appendicitis,2 cm below the umbilicus, centred on the midclavicular-mid inguinal line.</li><li>➤ Lanz incision : Transverse or skin crease incision for appendicitis,2 cm below the umbilicus, centred on the midclavicular-mid inguinal line.</li><li>➤ Lanz incision : Transverse or skin crease incision for appendicitis,2 cm below the umbilicus, centred on the midclavicular-mid inguinal line.</li><li>➤ Lanz incision</li><li>➤ Rocky-Davis incision: Transverse right lower quadrant incision. Rutherford-Morrison incision: oblique muscle cutting incision with its lower end over McBurney's point and extending obliquely upwards and laterally as necessary.</li><li>➤ Rocky-Davis incision: Transverse right lower quadrant incision.</li><li>➤ Rocky-Davis incision: Transverse right lower quadrant incision.</li><li>➤ Rocky-Davis incision:</li><li>➤ Rutherford-Morrison incision: oblique muscle cutting incision with its lower end over McBurney's point and extending obliquely upwards and laterally as necessary.</li><li>➤ Rutherford-Morrison incision: oblique muscle cutting incision with its lower end over McBurney's point and extending obliquely upwards and laterally as necessary.</li><li>➤ Rutherford-Morrison incision:</li><li>➤ Ref: Bailey and Love 28 th Ed. Pg 1344-45 .</li><li>➤ Ref:</li><li>➤ Bailey and Love 28 th Ed. Pg 1344-45</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient underwent an appendectomy for acute appendicitis. However, on the 6 th day following surgery, the patient experienced spiking fever, abdominal pain, malaise and diarrhoea. Which post op complication is being described here?", "options": [{"label": "A", "text": "Wound infection", "correct": false}, {"label": "B", "text": "Intra-abdominal abscess", "correct": true}, {"label": "C", "text": "Portal pyemia", "correct": false}, {"label": "D", "text": "Faecal fistula", "correct": false}], "correct_answer": "B. Intra-abdominal abscess", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Intra-abdominal abscess</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: Wound infection - Commonly presents with localized symptoms such as erythema, tenderness, and purulent discharge at the incision site , often occurring on the 4th or 5th day postoperatively , not typically associated with spiking fever or abdominal pain.</li><li>• Option A: Wound infection -</li><li>• localized symptoms</li><li>• erythema, tenderness, and purulent discharge at the incision site</li><li>• 4th or 5th day postoperatively</li><li>• Option C: Portal pyemia - A rare complication involving infection of the portal venous system , typically presenting with multiple liver abscesses, jaundice, and systemic illness.</li><li>• Option C: Portal pyemia -</li><li>• rare complication</li><li>• infection of the portal venous system</li><li>• Option D: Fecal fistula - Presents with fecal drainage from the wound or the formation of a persistent sinus tract ; this complication is less likely to cause spiking fever and would have distinct clinical signs.</li><li>• Option D: Fecal fistula</li><li>• fecal drainage from the wound or the formation of a persistent sinus tract</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The clinical presentation of a postoperative intra-abdominal abscess following appendectomy , includes delayed onset of spiking fever, abdominal pain, and malaise.</li><li>➤ clinical presentation of a postoperative intra-abdominal abscess</li><li>➤ appendectomy</li><li>➤ delayed onset of spiking fever, abdominal pain, and malaise.</li><li>➤ Abdominal ultrasonography and CT scanning greatly facilitate diagnosis and allow percutaneous drainage. Surgical exploration should be considered in patients suspected of having intra-abdominal sepsis. The most common complication however is wound infection typically occurring on the 4 th or 5 th day post op.</li><li>➤ Abdominal ultrasonography and CT scanning greatly facilitate diagnosis and allow percutaneous drainage.</li><li>➤ Abdominal ultrasonography and CT scanning greatly facilitate diagnosis and allow percutaneous drainage.</li><li>➤ Surgical exploration should be considered in patients suspected of having intra-abdominal sepsis.</li><li>➤ Surgical exploration should be considered in patients suspected of having intra-abdominal sepsis.</li><li>➤ The most common complication however is wound infection typically occurring on the 4 th or 5 th day post op.</li><li>➤ The most common complication however is wound infection typically occurring on the 4 th or 5 th day post op.</li><li>➤ most common complication however is wound infection</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 1347-1348</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 1347-1348</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "CT signs of appendicitis include an appendix measuring greater than ______ in diameter?", "options": [{"label": "A", "text": "4 mm", "correct": false}, {"label": "B", "text": "5 mm", "correct": false}, {"label": "C", "text": "6 mm", "correct": true}, {"label": "D", "text": "8 mm", "correct": false}], "correct_answer": "C. 6 mm", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• CT signs of appendicitis include an appendix measuring greater than 6mm in diameter and</li><li>• CT signs of appendicitis include an appendix measuring greater than 6mm in diameter and</li><li>• Appendiceal dilatation (&gt;6 mm outer diameter) Wall thickening (&gt;3 mm) and enhancement Thickening of the caecal apex: Caecal bar sign, A rrowhead sign Peri-appendiceal inflammation Focal wall non-enhancement representing necrosis (gangrenous appendicitis) and a precursor to perforation.</li><li>• Appendiceal dilatation (&gt;6 mm outer diameter)</li><li>• Appendiceal dilatation</li><li>• Wall thickening (&gt;3 mm) and enhancement</li><li>• Thickening of the caecal apex: Caecal bar sign, A rrowhead sign</li><li>• Caecal bar sign, A</li><li>• rrowhead sign</li><li>• Peri-appendiceal inflammation</li><li>• Focal wall non-enhancement representing necrosis (gangrenous appendicitis) and a precursor to perforation.</li><li>• (gangrenous appendicitis)</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• CT signs of appendicitis include an appendix measuring greater than 6 mm in diameter.</li><li>• Ref: Sabiston 21 st Ed. Pg 1305</li><li>• Ref:</li><li>• Sabiston 21 st Ed. Pg 1305</li><li>• Bailey 28 th Ed. Pg 1342.</li><li>• Bailey 28 th Ed. Pg 1342.</li><li>• Online source: https://doi.org/10.53347/rID-47125</li><li>• Online source:</li><li>• https://doi.org/10.53347/rID-47125</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A pregnant patient at 24 weeks' gestation presents with acute onset right lower quadrant pain, nausea, and leukocytosis. Appendicitis is suspected. Choose the incorrect statement concerning appendicitis in pregnancy.", "options": [{"label": "A", "text": "It's the most common extra uterine cause of acute abdomen in pregnancy", "correct": false}, {"label": "B", "text": "The cardinal feature of appendicitis in pregnancy is pain in the right lower quadrant", "correct": false}, {"label": "C", "text": "Conservative management by antibiotic should be tried", "correct": true}, {"label": "D", "text": "In cases of perforation, fetal mortality increases to 20%", "correct": false}], "correct_answer": "C. Conservative management by antibiotic should be tried", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: This is correct. Appendicitis is the most common extrauterine surgical emergency during pregnancy.</li><li>• Option A: This is correct.</li><li>• Option B: This is correct. The classic presentation of appendicitis, including right lower quadrant pain, remains the cardinal feature even in pregnancy, although the pain may shift as the uterus enlarges.</li><li>• Option B: This is correct.</li><li>• Option D: This is correct. The risk of fetal loss significantly increases in the presence of perforation, with mortality rates rising to 20% or more.</li><li>• Option D: This is correct.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The standard of care for appendicitis in pregnancy is prompt surgical intervention , not conservative management with antibiotics.</li><li>➤ standard of care for appendicitis in pregnancy</li><li>➤ surgical intervention</li><li>➤ conservative management with antibiotics.</li><li>➤ It is the most common extrauterine acute abdominal condition in pregnancy . Appendicitis is slightly more common in the second trimester. Pain in the right lower quadrant of the abdomen remains the cardinal feature of appendicitis in pregnancy. Delays in diagnosis or in the initiation of definitive treatment pose the greatest risk to the mother. Fetal loss occurs in 3-5% of cases of acute appendicitis in pregnancy but increases to 20% or more in the presence of perforation. There is insufficient evidence to support a non-operative approach and the pregnant patient with acute appendicitis should proceed to surgery. If the fetus is at a viable gestational age (23 weeks or more), appropriate obstetric and neonatal support should ideally be available.</li><li>➤ It is the most common extrauterine acute abdominal condition in pregnancy . Appendicitis is slightly more common in the second trimester.</li><li>➤ most common extrauterine acute abdominal condition</li><li>➤ in pregnancy</li><li>➤ Pain in the right lower quadrant of the abdomen remains the cardinal feature of appendicitis in pregnancy.</li><li>➤ Pain in the right lower quadrant</li><li>➤ cardinal feature</li><li>➤ Delays in diagnosis or in the initiation of definitive treatment pose the greatest risk to the mother. Fetal loss occurs in 3-5% of cases of acute appendicitis in pregnancy but increases to 20% or more in the presence of perforation.</li><li>➤ Fetal loss occurs in 3-5% of cases</li><li>➤ There is insufficient evidence to support a non-operative approach and the pregnant patient with acute appendicitis should proceed to surgery. If the fetus is at a viable gestational age (23 weeks or more), appropriate obstetric and neonatal support should ideally be available.</li><li>➤ Ref: Bailey and Love 28 th Ed. Pg 1346-47</li><li>➤ Ref: Bailey and Love 28 th Ed. Pg 1346-47</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "During the histopathological examination of an appendectomy specimen, a 1.5 cm tumor is identified at the base of the appendix. Which of the following statements regarding the management of appendicular neoplasms is incorrect?", "options": [{"label": "A", "text": "They are usually diagnosed during appendectomy for appendicitis", "correct": false}, {"label": "B", "text": "Most common type of appendicular neoplasm is a carcinoid", "correct": false}, {"label": "C", "text": "Size is the best predictor of malignant behaviour and metastatic potential", "correct": false}, {"label": "D", "text": "In tumours of size 1cm-2cm, negative margin appendicectomy is always done", "correct": true}], "correct_answer": "D. In tumours of size 1cm-2cm, negative margin appendicectomy is always done", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: This is correct. Appendicular neoplasms are often diagnosed incidentally during appendectomy for presumed appendicitis.</li><li>• Option A: This is correct.</li><li>• Option C: This is correct. The size of the tumor is considered the best predictor of malignant potential and metastatic risk in appendicular neoplasms.</li><li>• Option C: This is correct.</li><li>• Option D: This is incorrect. For tumors between 1cm-2cm, a negative margin appendectomy is not always done. The decision is based on factors such as involvement of mesentery, lymph nodes, and the presence of clear margins. Right hemicolectomy may be considered if these risk factors are present.</li><li>• Option D: This is incorrect.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Neuroendocrine tumors are the most common type of appendicular neoplasms , and the management of these tumors is determined by the size, location, and presence of risk factors for malignancy.</li><li>➤ Neuroendocrine tumors</li><li>➤ most common type of appendicular neoplasms</li><li>➤ size, location, and presence of risk factors for malignancy.</li><li>➤ NETs account for approximately 30-65% of appendix neoplasms while epithelial tumours account for most other cases. NETs arise in subepithelial neuroendocrine cells and the majority (70%) are located in the appendix tip. The average age at presentation is 40-50 years and most patients are asymptomatic with early-stage disease typically found at appendectomy for acute appendicitis. Uncommonly, patients may present with symptoms due to a mass or metastatic disease. Carcinoid syndrome is extremely rare. For tumors Up to 1 cm: Negative margin appendectomy done. In tumors of size 1 cm-2 cm: Right colectomy is done if mesentery is involved, enlarged LN, ki67 positivity with positive or unclear margins. In the absence of above, appendicectomy suffices. For tumors &gt; 2 cm: Right hemicolectomy.</li><li>➤ NETs account for approximately 30-65% of appendix neoplasms while epithelial tumours account for most other cases. NETs arise in subepithelial neuroendocrine cells and the majority (70%) are located in the appendix tip.</li><li>➤ The average age at presentation is 40-50 years and most patients are asymptomatic with early-stage disease typically found at appendectomy for acute appendicitis. Uncommonly, patients may present with symptoms due to a mass or metastatic disease. Carcinoid syndrome is extremely rare.</li><li>➤ For tumors Up to 1 cm: Negative margin appendectomy done.</li><li>➤ In tumors of size 1 cm-2 cm: Right colectomy is done if mesentery is involved, enlarged LN, ki67 positivity with positive or unclear margins. In the absence of above, appendicectomy suffices.</li><li>➤ For tumors &gt; 2 cm: Right hemicolectomy.</li><li>➤ Ref: Bailey and Love 28 th Ed. Pg 1349, Sabiston 21 st Ed. Pg 1315.</li><li>➤ Ref: Bailey and Love 28 th Ed. Pg 1349, Sabiston 21 st Ed. Pg 1315.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient with appendicitis was posted for an appendectomy procedure using the McBurney incision. Name the nerve most commonly injured with this incision.", "options": [{"label": "A", "text": "Ilioinguinal", "correct": false}, {"label": "B", "text": "11th thoracic", "correct": false}, {"label": "C", "text": "Iliohypogastric", "correct": true}, {"label": "D", "text": "Subcostal", "correct": false}], "correct_answer": "C. Iliohypogastric", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: The ilioinguinal nerve may be encountered in inguinal hernia repairs but is less likely to be injured in a McBurney incision for appendectomy.</li><li>• Option A:</li><li>• ilioinguinal nerve</li><li>• encountered in inguinal hernia repairs</li><li>• less likely to be injured in a McBurney incision</li><li>• Option B: The 11th thoracic nerve is not typically at risk during a McBurney incision , as this procedure is performed lower in the abdominal wall.</li><li>• Option B:</li><li>• 11th thoracic nerve</li><li>• not typically at risk during a McBurney incision</li><li>• Option D: The subcostal nerve is higher in the abdominal wall and is not associated with a McBurney incision.</li><li>• Option D:</li><li>• subcostal nerve is higher in the abdominal wall</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The iliohypogastric nerve is the most commonly injured nerve during an appendectomy performed using a McBurney incision.</li><li>➤ iliohypogastric nerve</li><li>➤ most commonly injured nerve</li><li>➤ appendectomy performed using a McBurney incision.</li><li>➤ The gridiron incision (described first by McArthur) is made at right angles to a line joining the anterior superior iliac spine to the umbilicus , its centre being along the line at McBurney’s point . If better access is required, it is possible to convert the gridiron to a Rutherford Morison incision (see below) by cutting the internal oblique and transverse muscles in the line of the incision. The iliohypogastric nerve is most commonly injured.</li><li>➤ The gridiron incision (described first by McArthur) is made at right angles to a line joining the anterior superior iliac spine to the umbilicus , its centre being along the line at McBurney’s point .</li><li>➤ gridiron incision</li><li>➤ right angles to a line joining the anterior superior iliac spine to the umbilicus</li><li>➤ McBurney’s point</li><li>➤ If better access is required, it is possible to convert the gridiron to a Rutherford Morison incision (see below) by cutting the internal oblique and transverse muscles in the line of the incision. The iliohypogastric nerve is most commonly injured.</li><li>➤ Rutherford Morison incision</li><li>➤ Ref: Bailey and Love 28 th Ed. Pg. 1344</li><li>➤ Ref: Bailey and Love 28 th Ed. Pg. 1344</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Meckel's diverticula in the inguinal hernia sac is called as?", "options": [{"label": "A", "text": "Amyand's hernia", "correct": false}, {"label": "B", "text": "Cooper's hernia", "correct": false}, {"label": "C", "text": "Richter’s hernia", "correct": false}, {"label": "D", "text": "Littre's hernia", "correct": true}], "correct_answer": "D. Littre's hernia", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Littre's hernia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: Amyand's hernia is characterized by the presence of a normal or inflamed appendix within an inguinal hernia sac.</li><li>• Option A: Amyand's hernia</li><li>• presence of a normal or inflamed appendix</li><li>• Option C: Richter’s hernia involves the herniation of only one sidewall of the bowel , which may lead to strangulation without causing intestinal obstruction.</li><li>• Option C: Richter’s hernia</li><li>• herniation of only one sidewall of the bowel</li><li>• Option D: Littre's hernia involves the presence of Meckel's diverticulum within an inguinal hernia sac and can potentially lead to complications such as intestinal obstruction.</li><li>• Option D: Littre's hernia</li><li>• presence of Meckel's diverticulum within an inguinal hernia sac</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Littre's hernia is the term for a hernia containing Meckel's diverticulum , which may present with complications like intestinal obstruction.</li><li>➤ Littre's hernia</li><li>➤ hernia containing Meckel's diverticulum</li><li>➤ intestinal obstruction.</li><li>➤ Ref : Bailey 28 th Ed. Pg 1060.</li><li>➤ Ref : Bailey 28 th Ed. Pg 1060.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is incorrect about Meckel’s diverticulum?", "options": [{"label": "A", "text": "In children, it presents with features mimicking acute appendicitis", "correct": true}, {"label": "B", "text": "It commonly arises from the ileum", "correct": false}, {"label": "C", "text": "Tc99m scan is used to demonstrate bleeding Meckel’s", "correct": false}, {"label": "D", "text": "Incidentally found Meckel’s can be left alone if it is broad based.", "correct": false}], "correct_answer": "A. In children, it presents with features mimicking acute appendicitis", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) In children, it presents with features mimicking acute appendicitis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option B: This is correct . It is found on the antimesenteric side of the ileum approximately 60 cm from the ileo-caecal valve and is classically 5 cm long (2% prevalence; 2 feet [60 cm] from ileo-caecal valve.</li><li>• Option B:</li><li>• correct</li><li>• Option C: If the stomach, duodenum and colon are excluded as a source of bleeding by endoscopy , radioisotope scanning with technetium-99m may demonstrate a Meckel’s diverticulum.</li><li>• Option C:</li><li>• stomach, duodenum and colon</li><li>• excluded as a source of bleeding</li><li>• endoscopy</li><li>• radioisotope scanning</li><li>• technetium-99m</li><li>• Option D: If a Meckel’s diverticulum is found incidentally at surgery , it can be left provided it has a wide mouth and is not thickened.</li><li>• Option D:</li><li>• Meckel’s diverticulum</li><li>• incidentally at surgery</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Meckel’s diverticulum in 20% cases contains ectopic gastric mucosa which may lead to ileal ulceration and painless PR bleed in children .</li><li>• Meckel’s diverticulum in 20% cases</li><li>• ectopic gastric mucosa</li><li>• ileal ulceration and painless PR bleed in children</li><li>• Ref: Bailey and Love 28 th Ed. Pg 1311-12.</li><li>• Ref:</li><li>• Bailey and Love 28 th Ed. Pg 1311-12.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Given below is a picture showing multiple polyps in a patient with Familial Adenomatous Polyposis (FAP). Which of the following statements regarding FAP is not true?", "options": [{"label": "A", "text": "Autosomal dominant condition due to mutation of the APC gene", "correct": false}, {"label": "B", "text": "More than 50 colonic adenomas are diagnostic", "correct": true}, {"label": "C", "text": "The lifetime risk of colorectal cancer is up to 100%", "correct": false}, {"label": "D", "text": "In a patient where the rectum is spared, total colectomy and ileorectal anastomosis can be considered as a treatment modality", "correct": false}], "correct_answer": "B. More than 50 colonic adenomas are diagnostic", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/28/picture2_KCxSdov.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B) More than 50 colonic adenomas are diagnostic</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: Autosomal dominant condition due to mutation of the APC gene - This is accurate as FAP is inherited in an autosomal dominant manner with mutations in the APC gene leading to the condition.</li><li>• Option A: Autosomal dominant condition due to mutation of the APC gene</li><li>• accurate as FAP is inherited in an autosomal dominant manner</li><li>• Option C: The lifetime risk of colorectal cancer is up to 100% - This is correct , as individuals with FAP almost invariably develop colorectal cancer if the colon is not removed.</li><li>• Option C: The lifetime risk of colorectal cancer is up to 100%</li><li>• correct</li><li>• Option D: In a patient where the rectum is spared, total colectomy and ileorectal anastomosis can be considered as a treatment modality - This is a true statement , as ileorectal anastomosis is an option for patients with FAP who have rectal sparing, though it necessitates careful surveillance of the remaining rectum.</li><li>• Option D: In a patient where the rectum is spared, total colectomy and ileorectal anastomosis can be considered as a treatment modality</li><li>• true statement</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In FAP , diagnosis requires over 100 adenomatous polyps , and while total colectomy with ileo-rectal anastomosis is a treatment option, regular monitoring of the rectum is essential due to the risk of malignancy.</li><li>➤ FAP</li><li>➤ diagnosis requires over 100 adenomatous polyps</li><li>➤ total colectomy with ileo-rectal anastomosis</li><li>➤ regular monitoring of the rectum</li><li>➤ The aim of surgery in FAP is to prevent the development of colorectal cancer. The surgical options are:</li><li>➤ The aim of surgery in FAP is to prevent the development of colorectal cancer. The surgical options are:</li><li>➤ The aim of surgery in FAP is to prevent the development of colorectal cancer. The surgical options are:</li><li>➤ The surgical options are:</li><li>➤ Restorative proctocolectomy with an ileal pouch–anal anastomosis; Colectomy with ileorectal anastomosis (IRA); Total proctocolectomy and end-ileostomy.</li><li>➤ Restorative proctocolectomy with an ileal pouch–anal anastomosis;</li><li>➤ Restorative proctocolectomy with an ileal pouch–anal anastomosis;</li><li>➤ Colectomy with ileorectal anastomosis (IRA);</li><li>➤ Colectomy with ileorectal anastomosis (IRA);</li><li>➤ Total proctocolectomy and end-ileostomy.</li><li>➤ Total proctocolectomy and end-ileostomy.</li><li>➤ NOTE: For patients with relative rectal sparing (&lt;20 polyps), total colectomy and IRA is an option to be considered, particularly as it is associated with less risk of sexual dysfunction in males and less infertility in females. However, the rectum requires regular endoscopic surveillance as up to 10% of patients will develop invasive malignancy in the rectum.</li><li>➤ NOTE:</li><li>➤ total colectomy and IRA</li><li>➤ rectum requires regular endoscopic surveillance</li></ul>\n<p><strong>References:</strong></p><ul><li>↳ Reference: Bailey and Love 28 th Ed., pg 1357</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Match the following class of polyps to its appropriate group.", "options": [{"label": "A", "text": "1-c, 2-a, 3-d, 4-b", "correct": false}, {"label": "B", "text": "1-b, 2-d, 3-a, 4-c", "correct": true}, {"label": "C", "text": "1-b, 2-c, 3-a, 4-d", "correct": false}, {"label": "D", "text": "1-d, 2-b, 3-a, 4-c", "correct": false}], "correct_answer": "B. 1-b, 2-d, 3-a, 4-c", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/28/screenshot-2024-03-28-163153.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/28/screenshot-2024-03-28-163502.jpg"], "explanation": "<p><strong>Ans. B) 1-b, 2-d, 3-a, 4-c</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old man was recently diagnosed for familial adenomatous polyposis syndrome. He has an 8-year-old child. The family knows that FAP will increase the risk of colorectal cancers significantly; they have agreed to get screened. Which modality will you use for screening?", "options": [{"label": "A", "text": "Genetic testing for APC gene mutation", "correct": true}, {"label": "B", "text": "Genetic testing for KRAS/BRAF gene mutation", "correct": false}, {"label": "C", "text": "Routine flexible sigmoidoscopy starting from 10 years of age", "correct": false}, {"label": "D", "text": "Routine flexible colonoscopy starting from 20 years of age", "correct": false}], "correct_answer": "A. Genetic testing for APC gene mutation", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Genetic testing for APC gene mutation</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option B: Testing for KRAS/BRAF gene mutations is not routinely performed for FAP screening as these are not the primary genes associated with FAP.</li><li>• Option B:</li><li>• Testing for KRAS/BRAF gene mutations</li><li>• not routinely performed for FAP screening</li><li>• Option C: Sigmoidoscopy can be initiated at age 10 if the genetic test is positive , or even if it's negative but there is a strong family history, for regular surveillance.</li><li>• Option C:</li><li>• Sigmoidoscopy</li><li>• initiated at age 10 if the genetic test is positive</li><li>• Option D: Routine colonoscopy is typically started later in adolescence unless there are symptoms or a positive genetic test indicating higher risk.</li><li>• Option D:</li><li>• Routine colonoscopy</li><li>• started later in adolescence</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Genetic testing for the APC gene mutation is the recommended initial screening step for children at risk for familial adenomatous polyposis syndrome .</li><li>➤ Genetic testing for the APC gene mutation</li><li>➤ initial screening step for children</li><li>➤ familial adenomatous polyposis syndrome</li><li>➤ Polyps are usually visible on sigmoidoscopy by the age of 15 years and will almost always be visible by the age of 30 years. Regular endoscopic surveillance in a suspected family member should therefore commence at the age of 12–14 years, even if a genetic mutation has not been identified. If the diagnosis is made during adolescence, surgery (prophylactic proctocolectomy) is usually deferred to the age of 17 or 18 years unless symptoms develop earlier.</li><li>➤ Polyps are usually visible on sigmoidoscopy by the age of 15 years and will almost always be visible by the age of 30 years. Regular endoscopic surveillance in a suspected family member should therefore commence at the age of 12–14 years, even if a genetic mutation has not been identified.</li><li>➤ Polyps are usually visible on sigmoidoscopy</li><li>➤ age of 15 years</li><li>➤ If the diagnosis is made during adolescence, surgery (prophylactic proctocolectomy) is usually deferred to the age of 17 or 18 years unless symptoms develop earlier.</li><li>➤ (prophylactic proctocolectomy)</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1356</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1356</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of the following are risk factors of colon cancer except?", "options": [{"label": "A", "text": "Ulcerative colitis", "correct": false}, {"label": "B", "text": "Cholecystectomy", "correct": false}, {"label": "C", "text": "Smoking", "correct": false}, {"label": "D", "text": "Human papilloma virus", "correct": true}], "correct_answer": "D. Human papilloma virus", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Human papilloma virus</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: Ulcerative colitis is known to be associated with an increased risk of colon cancer due to chronic inflammation of the colon .</li><li>• Option A: Ulcerative colitis</li><li>• increased risk of colon cancer</li><li>• chronic inflammation of the colon</li><li>• Option B: There is some evidence to suggest that cholecystectomy may marginally increase the risk of right-sided colon cancer.</li><li>• Option B:</li><li>• cholecystectomy</li><li>• marginally increase the risk of right-sided colon cancer.</li><li>• Option C: Smoking is a well-established risk factor for various cancers , including colon cancer .</li><li>• Option C: Smoking</li><li>• well-established risk factor for various cancers</li><li>• colon cancer</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ While ulcerative colitis , smoking , and possibly cholecystectomy are associated with an increased risk of colon cancer , HPV is not currently recognized as a risk factor for this disease.</li><li>➤ ulcerative colitis</li><li>➤ smoking</li><li>➤ cholecystectomy</li><li>➤ associated with an increased risk of colon cancer</li><li>➤ Worldwide, the prevalence of colorectal cancer is closely associated with the intake of red meat and particularly processed meat products (haem and N-nitroso compounds). A protective effect of dietary fibre is also suggested by epidemiological studies. A long-held hypothesis is that increased roughage is associated with reduced colonic transit times that in turn reduce exposure of the mucosa to dietary carcinogens. Conversely, high magnesium and calcium intake may be protective . The epidemiological evidence supporting prostaglandin inhibitors, particularly aspirin, in preventing colorectal cancer is substantial. Given the potential hazards of taking long-term aspirin, the challenge is to identify individuals for whom the protective benefits outweigh the harm. Other factors that increase the risk of developing colorectal cancer include inflammatory bowel disease (IBD) . Cholecystectomy may marginally increase the risk of right-sided colon cancer .</li><li>➤ Worldwide, the prevalence of colorectal cancer is closely associated with the intake of red meat and particularly processed meat products (haem and N-nitroso compounds). A protective effect of dietary fibre is also suggested by epidemiological studies.</li><li>➤ Worldwide, the prevalence of colorectal cancer is closely associated with the intake of red meat and particularly processed meat products (haem and N-nitroso compounds). A protective effect of dietary fibre is also suggested by epidemiological studies.</li><li>➤ A long-held hypothesis is that increased roughage is associated with reduced colonic transit times that in turn reduce exposure of the mucosa to dietary carcinogens.</li><li>➤ A long-held hypothesis is that increased roughage is associated with reduced colonic transit times that in turn reduce exposure of the mucosa to dietary carcinogens.</li><li>➤ Conversely, high magnesium and calcium intake may be protective .</li><li>➤ Conversely, high magnesium and calcium intake may be protective .</li><li>➤ high magnesium and calcium intake may be protective</li><li>➤ The epidemiological evidence supporting prostaglandin inhibitors, particularly aspirin, in preventing colorectal cancer is substantial. Given the potential hazards of taking long-term aspirin, the challenge is to identify individuals for whom the protective benefits outweigh the harm.</li><li>➤ The epidemiological evidence supporting prostaglandin inhibitors, particularly aspirin, in preventing colorectal cancer is substantial. Given the potential hazards of taking long-term aspirin, the challenge is to identify individuals for whom the protective benefits outweigh the harm.</li><li>➤ Other factors that increase the risk of developing colorectal cancer include inflammatory bowel disease (IBD) .</li><li>➤ Other factors that increase the risk of developing colorectal cancer include inflammatory bowel disease (IBD) .</li><li>➤ inflammatory bowel disease (IBD)</li><li>➤ Cholecystectomy may marginally increase the risk of right-sided colon cancer .</li><li>➤ Cholecystectomy may marginally increase the risk of right-sided colon cancer .</li><li>➤ right-sided colon cancer</li><li>➤ Ref : Bailey and Love, 28 th Ed., Pg 1359</li><li>➤ Ref : Bailey and Love, 28 th Ed., Pg 1359</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is not an extra-colonic manifestation of FAP?", "options": [{"label": "A", "text": "Hepatoblastoma", "correct": false}, {"label": "B", "text": "Renal cell carcinoma", "correct": true}, {"label": "C", "text": "Epidermoid cysts", "correct": false}, {"label": "D", "text": "Desmoid tumors", "correct": false}], "correct_answer": "B. Renal cell carcinoma", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Renal cell carcinoma</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Renal cell carcinoma is not commonly associated with Familial Adenomatous Polyposis as an extracolonic manifestation .</li><li>➤ Renal cell carcinoma</li><li>➤ not commonly associated with Familial Adenomatous Polyposis</li><li>➤ extracolonic manifestation</li><li>➤ Extracolonic manifestations of FAP</li><li>➤ Extracolonic manifestations of FAP</li><li>➤ Endodermal derivatives Adenomas and carcinomas, particularly around the duodenal ampulla but also stomach, small intestine, thyroid and biliary tree Gastric fundic gland polyps Hepatoblastoma (option A) Ectodermal derivatives Epidermoid cysts (Option C) Pilomatrixoma Congenital hypertrophy of the retinal pigment epithelium (CHRPE) Brain tumours Mesodermal derivatives Desmoid tumours (Option D) Osteomas Dental problems</li><li>➤ Endodermal derivatives Adenomas and carcinomas, particularly around the duodenal ampulla but also stomach, small intestine, thyroid and biliary tree Gastric fundic gland polyps Hepatoblastoma (option A)</li><li>➤ Endodermal derivatives</li><li>➤ Adenomas and carcinomas, particularly around the duodenal ampulla but also stomach, small intestine, thyroid and biliary tree Gastric fundic gland polyps Hepatoblastoma (option A)</li><li>➤ Adenomas and carcinomas, particularly around the duodenal ampulla but also stomach, small intestine, thyroid and biliary tree</li><li>➤ Gastric fundic gland polyps</li><li>➤ Hepatoblastoma (option A)</li><li>➤ Ectodermal derivatives Epidermoid cysts (Option C) Pilomatrixoma Congenital hypertrophy of the retinal pigment epithelium (CHRPE) Brain tumours</li><li>➤ Ectodermal derivatives</li><li>➤ Epidermoid cysts (Option C) Pilomatrixoma Congenital hypertrophy of the retinal pigment epithelium (CHRPE) Brain tumours</li><li>➤ Epidermoid cysts (Option C)</li><li>➤ Pilomatrixoma</li><li>➤ Congenital hypertrophy of the retinal pigment epithelium (CHRPE)</li><li>➤ (CHRPE)</li><li>➤ Brain tumours</li><li>➤ Mesodermal derivatives Desmoid tumours (Option D) Osteomas Dental problems</li><li>➤ Mesodermal derivatives</li><li>➤ Desmoid tumours (Option D) Osteomas Dental problems</li><li>➤ Desmoid tumours (Option D)</li><li>➤ Osteomas</li><li>➤ Dental problems</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg. 1357</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg. 1357</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is not used in the treatment of carcinoma of the sigmoid colon with acute obstruction?", "options": [{"label": "A", "text": "Hartmann's procedure", "correct": false}, {"label": "B", "text": "Left colectomy with anastomosis", "correct": false}, {"label": "C", "text": "Self expanding metal stent (SEMS)", "correct": false}, {"label": "D", "text": "Extended right hemicolectomy", "correct": true}], "correct_answer": "D. Extended right hemicolectomy", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Extended right hemicolectomy.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: Hartman's procedure is an option for left-sided colonic obstruction where the rectum is preserved.</li><li>• Option A:</li><li>• Hartman's procedure</li><li>• option for left-sided colonic obstruction</li><li>• Option B: Left colectomy with anastomosis is a definitive treatment that removes the diseased section and restores bowel continuity.</li><li>• Option B:</li><li>• Left colectomy with anastomosis</li><li>• definitive treatment that removes the diseased section</li><li>• Option C: SEMS can be used as a bridge to surgery or as palliative treatment in left-sided colonic obstruction.</li><li>• Option C:</li><li>• SEMS can be used as a bridge to surgery</li><li>• palliative treatment in left-sided colonic obstruction.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Extended right hemicolectomy is not used in the treatment of carcinoma of the left colon with acute obstruction; treatment options include left colectomy with or without anastomosis, or a stenting procedure.</li><li>➤ Extended right hemicolectomy</li><li>➤ not used</li><li>➤ treatment of carcinoma of the left colon with acute obstruction;</li><li>➤ left colectomy</li><li>➤ stenting procedure.</li><li>➤ Carcinoma of the left colon with obstruction can be treated in any of these ways depending on availability and expertise:</li><li>➤ Carcinoma of the left colon</li><li>➤ obstruction</li><li>➤ Left colectomy and anastomosis Left colectomy with Hartmann’s SEMS</li><li>➤ Left colectomy and anastomosis</li><li>➤ Left colectomy with Hartmann’s</li><li>➤ SEMS</li><li>➤ For a left-sided lesion, the decision lies between a Hartmann’s procedure and a resection and anastomosis. An on-table washout may be necessary to remove residual fecal content in the proximally obstructed bowel. Alternatively, removal of the whole proximal bowel may be required if the colon is markedly distended or if there is concern regarding its viability. Where endoscopic and radiological facilities are present, an obstructing left-sided lesion can often be treated initially with an expanding metal stent.</li><li>➤ For a left-sided lesion, the decision lies between a Hartmann’s procedure and a resection and anastomosis. An on-table washout may be necessary to remove residual fecal content in the proximally obstructed bowel.</li><li>➤ Alternatively, removal of the whole proximal bowel may be required if the colon is markedly distended or if there is concern regarding its viability.</li><li>➤ Where endoscopic and radiological facilities are present, an obstructing left-sided lesion can often be treated initially with an expanding metal stent.</li><li>➤ Overview:</li><li>➤ Overview:</li><li>➤ Right hemicolectomy: For cecum and ascending colon tumors</li><li>➤ Right hemicolectomy:</li><li>➤ Extended right hemicolectomy: For transverse colon tumors</li><li>➤ Extended right hemicolectomy:</li><li>➤ Left colectomy: For descending colon/sigmoid tumors</li><li>➤ Left colectomy:</li><li>➤ Anterior resection/APR: For rectal tumors</li><li>➤ Anterior resection/APR:</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1362.</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1362.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 65-year-old male came to the OPD with blood in stools and altered bowel habits. A lump was palpable in the left lower quadrant. The following barium study was obtained: Which statement is incorrect about the following condition?", "options": [{"label": "A", "text": "5-10% of patients will develop liver metastasis", "correct": true}, {"label": "B", "text": "Preferred Chemotherapy regimen is FOLFOX", "correct": false}, {"label": "C", "text": "IOC for staging is CECT abdomen and thorax", "correct": false}, {"label": "D", "text": "Rectum and sigmoid are the most commonly involved sites", "correct": false}], "correct_answer": "A. 5-10% of patients will develop liver metastasis", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/28/picture4_xR0Sc3N.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/28/picture5_0kgzuoM.jpg"], "explanation": "<p><strong>Ans. A) 5-10% patients will develop liver metastasis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option B: FOLFOX is indeed a preferred chemotherapy regimen for colorectal cancer .</li><li>• Option B:</li><li>• FOLFOX</li><li>• chemotherapy regimen for colorectal cancer</li><li>• Option C: CECT of the abdomen and thorax is typically used for staging to assess the extent of disease and the presence of metastasis.</li><li>• Option C:</li><li>• CECT</li><li>• abdomen and thorax</li><li>• staging to assess the extent of disease</li><li>• Option D: The rectum and sigmoid colon are common sites for colo-rectal cancers</li><li>• Option D:</li><li>• rectum and sigmoid colon</li><li>• colo-rectal cancers</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Liver metastasis occurs in at least 50% of colorectal cancer patients , not merely 5-10% as previously thought.</li><li>➤ Liver metastasis</li><li>➤ least 50% of colorectal cancer patients</li><li>➤ At least 50% patients develop metastasis of liver. Hematogenous spread is most commonly to the liver via the portal vein . One-third of patients will have liver metastases at the time of diagnosis and 50% will develop metastases at some point, accounting for the majority of deaths. IOC: For diagnosis - Colonoscopy with biopsy For staging - CECT abdomen Most large bowel cancers arise from the left colon, notably the rectum (38%), sigmoid (21%) and descending colon (4%). Cancer of the caecum (12%) and ascending colon (5%) is less common but may be gradually increasing in incidence. Cancer of the transverse colon (5.5%), flexures (2–3%) and appendix (0.5%) are relatively uncommon.</li><li>➤ At least 50% patients develop metastasis of liver. Hematogenous spread is most commonly to the liver via the portal vein . One-third of patients will have liver metastases at the time of diagnosis and 50% will develop metastases at some point, accounting for the majority of deaths.</li><li>➤ Hematogenous spread is most commonly to the liver via the portal vein</li><li>➤ IOC: For diagnosis - Colonoscopy with biopsy For staging - CECT abdomen</li><li>➤ IOC:</li><li>➤ For diagnosis - Colonoscopy with biopsy For staging - CECT abdomen</li><li>➤ For diagnosis - Colonoscopy with biopsy</li><li>➤ For diagnosis -</li><li>➤ For staging - CECT abdomen</li><li>➤ For staging -</li><li>➤ Most large bowel cancers arise from the left colon, notably the rectum (38%), sigmoid (21%) and descending colon (4%). Cancer of the caecum (12%) and ascending colon (5%) is less common but may be gradually increasing in incidence. Cancer of the transverse colon (5.5%), flexures (2–3%) and appendix (0.5%) are relatively uncommon.</li><li>➤ rectum (38%), sigmoid (21%)</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 1359.</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 1359.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In individuals with Gardner's syndrome, which is a subtype of Familial Adenomatous Polyposis (FAP), which facial abnormality is most frequently encountered?", "options": [{"label": "A", "text": "Multiple osteomas", "correct": true}, {"label": "B", "text": "Dental cysts", "correct": false}, {"label": "C", "text": "Mucosal neuromas", "correct": false}, {"label": "D", "text": "Macroglossia", "correct": false}], "correct_answer": "A. Multiple osteomas", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Multiple osteoma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Gardner’s syndrome is a variant of FAP. They are associated with:</li><li>• Gardner’s syndrome is a variant of FAP. They are associated with:</li><li>• Osteomas (Mandible is M/C) Congenital hypertrophied retinal pigmented epithelium Desmoid tumours Sebaceous cysts Extra teeth</li><li>• Osteomas (Mandible is M/C)</li><li>• (Mandible is M/C)</li><li>• Congenital hypertrophied retinal pigmented epithelium</li><li>• Desmoid tumours</li><li>• Sebaceous cysts</li><li>• Extra teeth</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Multiple osteomas are the most common facial abnormality in Gardner's syndrome , which is a variant of Familial Adenomatous Polyposis (FAP).</li><li>➤ Multiple osteomas</li><li>➤ most common facial abnormality in Gardner's syndrome</li><li>➤ Familial Adenomatous Polyposis</li><li>➤ Ref : Bailey 28th Ed. Pg 1356-57</li><li>➤ Ref : Bailey 28th Ed. Pg 1356-57</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 25-year-old patient presented with tenesmus, diarrhea, and bleeding. Blood investigation shows the presence of p-ANCA, and stools show calprotectin. What is the incorrect statement concerning the above disease?", "options": [{"label": "A", "text": "Colonoscopy shows the presence of pseudo-polyps", "correct": false}, {"label": "B", "text": "Has a bimodal age presentation", "correct": false}, {"label": "C", "text": "Treatment involves total proctocolectomy with ileoanal pouch anastomosis", "correct": false}, {"label": "D", "text": "Childhood appendectomy is a risk factor", "correct": true}], "correct_answer": "D. Childhood appendectomy is a risk factor", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Childhood appendectomy is a risk factor</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: The presence of pseudo-polyps on colonoscopy is typical in patients with a history of ulcerative colitis , indicating areas of regenerative mucosa where inflammation has receded.</li><li>• Option A:</li><li>• pseudo-polyps on colonoscopy</li><li>• ulcerative colitis</li><li>• areas of regenerative mucosa</li><li>• Option B: Ulcerative colitis can present at any age , but it often has a bimodal distribution, with peaks in younger adults (20s-30s) and then again in later adulthood (50s-60s).</li><li>• Option B: Ulcerative colitis</li><li>• present at any age</li><li>• bimodal distribution, with peaks in younger adults</li><li>• Option C: For patients with severe ulcerative colitis or when there's a high risk of cancer , treatment can involve total proctocolectomy with ileoanal pouch anastomosis to remove the diseased colon and rectum.</li><li>• Option C:</li><li>• severe ulcerative colitis</li><li>• high risk of cancer</li><li>• total proctocolectomy with ileoanal pouch</li><li>• remove the diseased colon and rectum.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Childhood appendectomy is generally considered protective against the development of ulcerative colitis , contradicting the notion that it is a risk factor.</li><li>➤ Childhood appendectomy</li><li>➤ considered protective against the development of ulcerative colitis</li><li>➤ Clinical features:</li><li>➤ Clinical features:</li><li>➤ If inflammation is confined to the rectum (proctitis), there is usually no systemic upset, and extra-alimentary manifestations are rare. Features include rectal bleeding, tenesmus, and mucous discharge . The disease often remains confined to the rectum, usually with a benign course. Colitis is almost always associated with bloody diarrhea and urgency . Severe and/or extensive colitis may result in anemia, hypoproteinaemia and electrolyte disturbances</li><li>➤ If inflammation is confined to the rectum (proctitis), there is usually no systemic upset, and extra-alimentary manifestations are rare.</li><li>➤ If inflammation is confined to the rectum (proctitis), there is usually no systemic upset, and extra-alimentary manifestations are rare.</li><li>➤ Features include rectal bleeding, tenesmus, and mucous discharge . The disease often remains confined to the rectum, usually with a benign course. Colitis is almost always associated with bloody diarrhea and urgency . Severe and/or extensive colitis may result in anemia, hypoproteinaemia and electrolyte disturbances</li><li>➤ Features include rectal bleeding, tenesmus, and mucous discharge . The disease often remains confined to the rectum, usually with a benign course. Colitis is almost always associated with bloody diarrhea and urgency . Severe and/or extensive colitis may result in anemia, hypoproteinaemia and electrolyte disturbances</li><li>➤ rectal bleeding, tenesmus, and mucous</li><li>➤ discharge</li><li>➤ Colitis is almost always associated with bloody diarrhea and urgency</li><li>➤ Colonoscopy: Where there has been remission and relapse, there may be regenerative mucosal nodules or pseudopolyps. Later, tiny ulcers may be seen that appear to coalesce. The biopsy will show crypt distortion, cryptitis/crypt abscess with marked infiltration of plasma cells within the deep lamina propria (basal plasmacytosis), and mucus depletion.</li><li>➤ Colonoscopy:</li><li>➤ The biopsy will show crypt distortion, cryptitis/crypt abscess</li><li>➤ (basal plasmacytosis),</li><li>➤ Ref: Bailey and Love, 28 th Ed Pg 1318-21.</li><li>➤ Ref: Bailey and Love, 28 th Ed Pg 1318-21.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of these are indications for surgical management of ulcerative colitis (UC) except?", "options": [{"label": "A", "text": "Growth retardation", "correct": false}, {"label": "B", "text": "Steroid dependence", "correct": false}, {"label": "C", "text": "Left-sided colitis", "correct": true}, {"label": "D", "text": "Extra-intestinal UC", "correct": false}], "correct_answer": "C. Left-sided colitis", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Left-sided colitis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: Growth retardation in the context of UC can be an indication for surgery , especially when it affects the development of children or adolescents and is not manageable with medical therapy alone.</li><li>• Option A:</li><li>• Growth retardation</li><li>• UC can be an indication for surgery</li><li>• Option B: Steroid dependence indicates that a patient cannot maintain remission without ongoing steroid treatment, which may lead to substantial side effects, making surgery a viable option to consider for long-term management.</li><li>• Option B:</li><li>• Steroid dependence</li><li>• patient cannot maintain remission without ongoing steroid treatment,</li><li>• Option D: Extra-intestinal manifestations of UC can be severe and sometimes not responsive to medical therapy for the underlying bowel disease . In such cases, surgical intervention might be required to manage the systemic complications of UC.</li><li>• Option D:</li><li>• Extra-intestinal manifestations</li><li>• severe</li><li>• medical therapy for the underlying bowel disease</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Left-sided colitis alone, typically well-controlled medically, is generally not an indication for surgical intervention in ulcerative colitis.</li><li>➤ Left-sided colitis</li><li>➤ well-controlled medically,</li><li>➤ not an indication for surgical intervention in ulcerative colitis.</li><li>➤ The indications for surgery in UC are:</li><li>➤ The indications for surgery in UC are:</li><li>➤ Severe or fulminating disease/toxic megacolon failing to respond to medical therapy; Chronic disease with anemia, frequent stools, urgency and tenesmus; Steroid-dependent disease where remission cannot be maintained without substantial doses of steroids with harmful side effects; Intolerance or side effects of medical therapy required to control the disease, e.g., steroid psychosis, azathioprine induced pancreatitis; Growth retardation in children or adolescents; Neoplastic change: patients who have severe dysplasia or carcinoma; Associated sclerosing cholangitis; Extraintestinal manifestations;</li><li>➤ Severe or fulminating disease/toxic megacolon failing to respond to medical therapy;</li><li>➤ Chronic disease with anemia, frequent stools, urgency and tenesmus;</li><li>➤ Steroid-dependent disease where remission cannot be maintained without substantial doses of steroids with harmful side effects;</li><li>➤ Intolerance or side effects of medical therapy required to control the disease, e.g., steroid psychosis, azathioprine induced pancreatitis;</li><li>➤ Growth retardation in children or adolescents;</li><li>➤ Neoplastic change: patients who have severe dysplasia or carcinoma;</li><li>➤ Neoplastic change:</li><li>➤ Associated sclerosing cholangitis;</li><li>➤ Extraintestinal manifestations;</li><li>➤ Surgeries for UC:</li><li>➤ Surgeries for UC:</li><li>➤ Pan-proctocolectomy with reconstruction: This operation removes the entire colon and rectum and, by doing so, removes any risk of colorectal neoplasia or colitis symptoms.</li><li>➤ Pan-proctocolectomy with reconstruction:</li><li>➤ Reconstruction can be in the form of:</li><li>➤ Reconstruction can be in the form of:</li><li>➤ Permanent end ileostomy: indicated for patients who are not candidates for restorative surgery owing to impaired anal sphincter function, comorbidities or patient preference. Ileal pouch (J pouch) anal anastomosis: For young fit patients with good anal tone. Pouchitis is inflammation of the ileal pouch mucosa that occurs to varying degrees in up to 50% of patients who undergo IPAA for UC.</li><li>➤ Permanent end ileostomy: indicated for patients who are not candidates for restorative surgery owing to impaired anal sphincter function, comorbidities or patient preference.</li><li>➤ Permanent end ileostomy:</li><li>➤ Ileal pouch (J pouch) anal anastomosis: For young fit patients with good anal tone. Pouchitis is inflammation of the ileal pouch mucosa that occurs to varying degrees in up to 50% of patients who undergo IPAA for UC.</li><li>➤ Ileal pouch (J pouch) anal anastomosis:</li><li>➤ Pouchitis</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 1324-26</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 1324-26</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 35-year-old female is brought to casualty with abdominal pain and diarrhoea. She is a known case of sigmoid diverticular disease. She undergoes laparotomy and is found to have fecal collection in the pelvis and paracolic gutters. What is her Hinchey stage?", "options": [{"label": "A", "text": "1", "correct": false}, {"label": "B", "text": "2", "correct": false}, {"label": "C", "text": "3", "correct": false}, {"label": "D", "text": "4", "correct": true}], "correct_answer": "D. 4", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/28/picture8_s8T1Gmi.jpg"], "explanation": "<p><strong>Ans. D) 4</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Fecal peritonitis is Hinchey's stage 4 of diverticular perforation.</li><li>• Fecal peritonitis is Hinchey's stage 4 of diverticular perforation.</li><li>• Option A (Hinchey 1) indicates a localized pericolic or mesenteric abscess.</li><li>• Option A (Hinchey 1)</li><li>• localized pericolic or mesenteric abscess.</li><li>• Option B (Hinchey 2 ) refers to a pelvic or retroperitoneal abscess.</li><li>• Option B (Hinchey 2</li><li>• pelvic or retroperitoneal abscess.</li><li>• Option C (Hinchey 3) means generalized purulent peritonitis , which is an infection in the abdominal cavity.</li><li>• Option C (Hinchey 3)</li><li>• generalized purulent peritonitis</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Hinchey classification is critical in diagnosing the severity of diverticulitis and guiding appropriate treatment plans , including surgical intervention. Fecal peritonitis , as indicated by Hinchey Stage 4 , often requires urgent surgical management due to the high risk of widespread infection and sepsis.</li><li>➤ Hinchey classification</li><li>➤ diagnosing the severity of diverticulitis and guiding appropriate treatment plans</li><li>➤ surgical intervention.</li><li>➤ Fecal peritonitis</li><li>➤ Hinchey Stage 4</li><li>➤ urgent surgical management</li><li>➤ high risk of widespread infection and sepsis.</li><li>➤ Location: Diverticula are found in the left colon in around 75% of those over 70 years of age in the Western world. The condition is overwhelmingly found in the sigmoid colon but can affect the whole colon.</li><li>➤ Location:</li><li>➤ Complications of diverticular disease:</li><li>➤ Complications of diverticular disease:</li><li>➤ Diverticulitis Abscess Peritonitis Intestinal obstruction Haemorrhage Fistula formation</li><li>➤ Diverticulitis</li><li>➤ Diverticulitis</li><li>➤ Abscess</li><li>➤ Abscess</li><li>➤ Peritonitis</li><li>➤ Peritonitis</li><li>➤ Intestinal obstruction</li><li>➤ Intestinal obstruction</li><li>➤ Haemorrhage</li><li>➤ Haemorrhage</li><li>➤ Fistula formation</li><li>➤ Fistula formation</li><li>➤ Clinical features: Uncomplicated diverticulitis have minimal clinical features.</li><li>➤ Clinical features:</li><li>➤ Diverticulitis typically presents as persistent lower abdominal pain. There may be accompanying diarrhoea or constipation . The lower abdomen is tender, especially over the left iliac fossa, but occasionally also on the right side if the sigmoid loop lies across the midline. The sigmoid colon may be tender and thickened on palpation and rectal examination may reveal a tender mass if an abscess has formed.</li><li>➤ diarrhoea or constipation</li><li>➤ Hinchey grades of perforated diverticulitis:</li><li>➤ Hinchey grades of perforated diverticulitis:</li><li>➤ Grade I - Mesenteric or pericolic abscess Grade II - Pelvic abscess Grade III - Purulent peritonitis Grade IV - Faecal peritonitis</li><li>➤ Grade I - Mesenteric or pericolic abscess</li><li>➤ Grade I - Mesenteric or pericolic abscess</li><li>➤ Grade I</li><li>➤ Grade II - Pelvic abscess</li><li>➤ Grade II - Pelvic abscess</li><li>➤ Grade II</li><li>➤ Grade III - Purulent peritonitis</li><li>➤ Grade III - Purulent peritonitis</li><li>➤ Grade III</li><li>➤ Grade IV - Faecal peritonitis</li><li>➤ Grade IV - Faecal peritonitis</li><li>➤ Grade IV</li><li>➤ Diagnosis:</li><li>➤ Diagnosis:</li><li>➤ Spiral CT has excellent sensitivity and specificity for identifying bowel wall thickening, abscess formation and extraluminal disease and has revolutionised the assessment of complicated diverticular disease. Endoscopic assessment may demonstrate the necks of diverticula within the bowel lumen in uncomplicated cases.</li><li>➤ Spiral CT has excellent sensitivity and specificity for identifying bowel wall thickening, abscess formation and extraluminal disease and has revolutionised the assessment of complicated diverticular disease.</li><li>➤ Spiral CT has excellent sensitivity and specificity for identifying bowel wall thickening, abscess formation and extraluminal disease and has revolutionised the assessment of complicated diverticular disease.</li><li>➤ Spiral CT has excellent sensitivity and specificity</li><li>➤ Endoscopic assessment may demonstrate the necks of diverticula within the bowel lumen in uncomplicated cases.</li><li>➤ Endoscopic assessment may demonstrate the necks of diverticula within the bowel lumen in uncomplicated cases.</li><li>➤ Treatment: Uncomplicated diverticulitis are managed with laxatives.</li><li>➤ Treatment:</li><li>➤ Acute diverticulitis has been traditionally treated with intravenous antibiotics and bowel rest.</li><li>➤ Principles of surgical management of diverticular disease:</li><li>➤ Principles of surgical management of diverticular disease:</li><li>➤ Hartmann’s procedure is often the safest option in an emergency setting Primary anastomosis (with or without proximal diversion) can be considered in selected patients Elective resection may be considered for recurrent attacks or complications</li><li>➤ Hartmann’s procedure is often the safest option in an emergency setting</li><li>➤ Hartmann’s procedure is often the safest option in an emergency setting</li><li>➤ Primary anastomosis (with or without proximal diversion) can be considered in selected patients</li><li>➤ Primary anastomosis (with or without proximal diversion) can be considered in selected patients</li><li>➤ Elective resection may be considered for recurrent attacks or complications</li><li>➤ Elective resection may be considered for recurrent attacks or complications</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 1368-69-70.</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 1368-69-70.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "During a colonoscopy, which finding is associated with the highest potential for malignancy?", "options": [{"label": "A", "text": "Single sessile polyp", "correct": false}, {"label": "B", "text": "Single pedunculated polyp", "correct": false}, {"label": "C", "text": "Multiple sessile polyps", "correct": true}, {"label": "D", "text": "Multiple pedunculated polyps", "correct": false}], "correct_answer": "C. Multiple sessile polyps", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Multiple sessile polyps</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Sessile and particularly depressed lesions have more malignant potential than pedunculated lesions . The risk of malignant change increases with size , almost one-third of large (&gt;3 cm) colonic adenomas will have an area of invasive malignancy. More the number of polyps, more is the malignant potential . Recent guidelines published by the British Society of Gastroenterology have identified patients at high risk needing follow-up colonoscopy as those with either:</li><li>• Sessile and particularly depressed lesions have more malignant potential than pedunculated lesions .</li><li>• Sessile</li><li>• depressed lesions</li><li>• more malignant potential than pedunculated lesions</li><li>• The risk of malignant change increases with size , almost one-third of large (&gt;3 cm) colonic adenomas will have an area of invasive malignancy.</li><li>• risk of malignant change increases with size</li><li>• More the number of polyps, more is the malignant potential .</li><li>• More the number of polyps, more is the malignant potential</li><li>• Recent guidelines published by the British Society of Gastroenterology have identified patients at high risk needing follow-up colonoscopy as those with either:</li><li>• Two or more premalignant polyps , including at least one advanced colorectal polyp (defined as a serrated polyp ≥10 mm in size or containing any grade of dysplasia or as an adenoma ≥10 mm in size or containing high-grade dysplasia);</li><li>• Two or more premalignant polyps</li><li>• least one advanced colorectal polyp</li><li>• OR</li><li>• OR</li><li>• Five or more premalignant polyps.</li><li>• Five or more premalignant polyps.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Multiple sessile polyps are associated with a higher risk of malignant transformation compared to single or pedunculated polyps , especially as the size of the adenomas increases .</li><li>➤ Multiple sessile polyps</li><li>➤ higher risk of malignant transformation</li><li>➤ single or pedunculated polyps</li><li>➤ size of the adenomas increases</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1356</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1356</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the correct statement for the Amsterdam II criteria.", "options": [{"label": "A", "text": "FAP and Lynch syndromes can be diagnosed using this criterion", "correct": false}, {"label": "B", "text": "At least one polyp diagnosed before 50 years", "correct": false}, {"label": "C", "text": "Tumors are verified by radiological examination", "correct": false}, {"label": "D", "text": "At least 2 successive generations affected", "correct": true}], "correct_answer": "D. At least 2 successive generations affected", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) At least 2 successive generations affected</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: FAP and Lynch syndromes can be diagnosed using this criterion - This is incorrect because the Amsterdam II criteria specifically relate to Lynch syndrome , not FAP.</li><li>• Option A: FAP and Lynch syndromes can be diagnosed using this criterion</li><li>• Amsterdam II criteria specifically relate to Lynch syndrome</li><li>• Option B: At least one polyp diagnosed before 50 years - The Amsterdam II criteria involve at least one cancer (not just a polyp) diagnosed before the age of 50 years .</li><li>• Option B:</li><li>• At least one polyp diagnosed before 50 years</li><li>• least one cancer</li><li>• diagnosed before the age of 50 years</li><li>• Option C: Tumors are verified by radiological examination - This is incorrect. The diagnosis of tumors in Lynch syndrome is verified by pathological examination, not just radiological examination.</li><li>• Option C: Tumors are verified by radiological examination</li><li>• diagnosis of tumors in Lynch syndrome</li><li>• pathological examination,</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The components of the Amsterdam II criteria for Lynch syndrome , which include at least one cancer diagnosed before 50 years , involvement of at least three family members (one of whom is a first-degree relative of the others), and that at least two successive generations are affected.</li><li>➤ components of the Amsterdam II</li><li>➤ Lynch syndrome</li><li>➤ include at least one cancer diagnosed before 50 years</li><li>➤ least three family members</li><li>➤ AMSTERDAM II criteria: (3-2-1)</li><li>➤ AMSTERDAM II criteria:</li><li>➤ Three or more family members with a Lynch syndrome-related cancer (colorectal, endometrial, small bowel, ureter, renal pelvis), one of whom is a first-degree relative of the other two .</li><li>➤ Three</li><li>➤ or more</li><li>➤ family members</li><li>➤ Lynch syndrome-related cancer</li><li>➤ first-degree relative of the other two</li><li>➤ Two or more successive affected generations At least one tumour diagnosed before the age of 50 years FAP excluded Tumours verified by pathological examination</li><li>➤ Two or more successive affected generations</li><li>➤ Two</li><li>➤ At least one tumour diagnosed before the age of 50 years</li><li>➤ one</li><li>➤ FAP excluded</li><li>➤ Tumours verified by pathological examination</li><li>➤ Because of the accelerated pathway from adenoma to cancer in Lynch syndrome those with a gene mutation should be offered 2-yearly endoscopic surveillance from age 25 years (MLH1 and MSH2 carriers) or 35 years (MSH6 carriers).</li><li>➤ 2-yearly endoscopic surveillance from age 25 years (MLH1 and MSH2 carriers) or 35 years (MSH6 carriers).</li><li>➤ Ref: Bailey and Love 28 th Ed. Pg. 1358</li><li>➤ Ref:</li><li>➤ Bailey and Love 28 th Ed. Pg. 1358</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the marked area:", "options": [{"label": "A", "text": "Sudeck's point", "correct": false}, {"label": "B", "text": "Arc of Riolan", "correct": false}, {"label": "C", "text": "Griffiths poi", "correct": true}, {"label": "D", "text": "Drummonds arcade", "correct": false}], "correct_answer": "C. Griffiths poi", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/28/picture1_9tUjjgh.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Griffith’s point</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: Sudeck's point refers to the critical point of blood supply at the rectosigmoid junction , which is not indicated in the image.</li><li>• Option A:</li><li>• Sudeck's point</li><li>• critical point of blood supply</li><li>• rectosigmoid junction</li><li>• Option B: The Arc of Riolan is an anastomotic vessel that connects the superior mesenteric artery (SMA) with the inferior mesenteric artery (IMA), but it is not what is marked in the image.</li><li>• Option B:</li><li>• Arc of Riolan</li><li>• anastomotic vessel that connects the superior mesenteric artery</li><li>• inferior mesenteric artery</li><li>• Option D: Drummond's arcade is the marginal artery along the colon that provides blood supply close to the colonic wall but does not refer to a specific watershed area.</li><li>• Option D:</li><li>• Drummond's arcade</li><li>• marginal artery</li><li>• colon that provides blood supply</li><li>• colonic wall</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Griffith's point is the watershed area located at the splenic flexure of the colon , which is vulnerable to ischemia in cases of acute mesenteric ischemia .</li><li>➤ Griffith's point</li><li>➤ watershed area located at the splenic flexure of the colon</li><li>➤ vulnerable to ischemia</li><li>➤ acute mesenteric ischemia</li><li>➤ Watershed areas of the colon:</li><li>➤ Watershed areas of the colon:</li><li>➤ Rectosigmoid junction - Sudeck’s point</li><li>➤ Rectosigmoid junction</li><li>➤ Arc of Riolan: Anastomosis between SMA and IMA</li><li>➤ Arc of Riolan:</li><li>➤ Marginal arcade of Drummond: Anastomotic branches of colic arteries near the wall.</li><li>➤ Marginal arcade of Drummond:</li><li>➤ Peripheral branches of the superior and inferior mesenteric vessels usually anastomose, resulting in a continuous vascular supply along the colon, referred to as the marginal artery of Drummond . This vessel is often the key blood supply to the vascular arcades, ensuring adequate perfusion of a colonic anastomosis; however, blood flow in the ‘watershed’ area of the splenic flexure representing the junction of the embryological midgut and hindgut may be tenuous. Sudden occlusion of the inferior mesenteric artery may leave the area of the splenic flexure poorly perfused, leading to an ischaemic colitis</li><li>➤ Peripheral branches of the superior and inferior mesenteric vessels usually anastomose, resulting in a continuous vascular supply along the colon, referred to as the marginal artery of Drummond . This vessel is often the key blood supply to the vascular arcades, ensuring adequate perfusion of a colonic anastomosis; however, blood flow in the ‘watershed’ area of the splenic flexure representing the junction of the embryological midgut and hindgut may be tenuous.</li><li>➤ marginal artery of Drummond</li><li>➤ Sudden occlusion of the inferior mesenteric artery may leave the area of the splenic flexure poorly perfused, leading to an ischaemic colitis</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1354</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1354</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 60-year-old woman undergoes a screening colonoscopy after her family doctor's recommendation. She has no family history of colon cancer. A single polyp was found during the colonoscopy and a biopsy was taken. Which of the following findings in the biopsy will carry the highest risk of malignancy?", "options": [{"label": "A", "text": "Villous adenoma", "correct": true}, {"label": "B", "text": "Hyperplastic polyps", "correct": false}, {"label": "C", "text": "Tubular adenoma", "correct": false}, {"label": "D", "text": "Inflammatory polyps", "correct": false}], "correct_answer": "A. Villous adenoma", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Villous adenoma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option B: Hyperplastic polyps are typically considered to have a very low risk of malignancy and are often found incidentally.</li><li>• Option B:</li><li>• Hyperplastic polyps</li><li>• very low risk of malignancy</li><li>• Option C: Tubular adenomas do have a potential for malignancy , but less so than villous adenomas, especially when small and without dysplasia.</li><li>• Option C:</li><li>• Tubular adenomas</li><li>• potential for malignancy</li><li>• Option D: Inflammatory polyps are usually associated with inflammatory bowel disease and are not typically precancerous , though they can occur alongside dysplastic changes in chronic conditions.</li><li>• Option D:</li><li>• Inflammatory polyps</li><li>• inflammatory bowel disease</li><li>• not typically precancerous</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Villous adenomas have the highest risk of malignancy among the polyp types due to their histological structure .</li><li>➤ Villous adenomas</li><li>➤ highest risk of malignancy</li><li>➤ polyp types due to their histological structure</li></ul>\n<p><strong>References:</strong></p><ul><li>↳ Reference:</li><li>↳ Bailey and Love, 28 th Ed. Pg 1355</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A newborn presents with delayed passage of meconium, abdominal distension, and bilious vomiting. The contrast enema picture is as follows. What is the investigation of choice to diagnose the disease?", "options": [{"label": "A", "text": "CT scan", "correct": false}, {"label": "B", "text": "Colonoscopy", "correct": false}, {"label": "C", "text": "Suction Rectal biopsy", "correct": true}, {"label": "D", "text": "MR Defecography", "correct": false}], "correct_answer": "C. Suction Rectal biopsy", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/28/picture3_HnFAXRu.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Suction Rectal biopsy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: CT scan can visualize the bowel anatomy , but it is not diagnostic for Hirschsprung disease.</li><li>• Option A:</li><li>• CT scan</li><li>• visualize the bowel anatomy</li><li>• Option B: Colonoscopy allows direct visualization of the bowel but cannot diagnose Hirschsprung disease as it does not assess for the absence of ganglion cells.</li><li>• Option B:</li><li>• Colonoscopy</li><li>• direct visualization of the bowel</li><li>• Option D: MR Defecography is used to visualize pelvic floor function and is not used in the diagnosis of Hirschsprung disease.</li><li>• Option D:</li><li>• MR Defecography</li><li>• visualize pelvic floor function</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Suction Rectal biopsy is the standard diagnostic test for Hirschsprung disease , as it can confirm the absence of enteric ganglion cells.</li><li>➤ Suction Rectal biopsy</li><li>➤ standard diagnostic test for Hirschsprung disease</li><li>➤ absence of enteric ganglion cells.</li><li>➤ Pathology: Aganglionic bowel fails to relax, causing a functional obstruction .</li><li>➤ Pathology:</li><li>➤ functional obstruction</li><li>➤ Presentation: Hirschsprung’s disease presents with delayed passage of meconium, abdominal distension and bilious vomiting</li><li>➤ Presentation:</li><li>➤ Diagnosis: Suction Rectal biopsy &gt; Full-thickness biopsy</li><li>➤ Diagnosis:</li><li>➤ Suction Rectal biopsy &gt; Full-thickness biopsy</li><li>➤ Surgery: Swenson, Duhamel, Yancey–Soave and trans-anal ‘pull-through’ procedures.</li><li>➤ Surgery:</li><li>➤ Ref: Bailey and Love’s Short Practice of surgery 28 th edition pg 269-270</li><li>➤ Ref: Bailey and Love’s Short Practice of surgery 28 th edition pg 269-270</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the incorrect statement concerning Lynch syndrome.", "options": [{"label": "A", "text": "It is an autosomal dominant condition", "correct": false}, {"label": "B", "text": "Lifetime risk of developing colorectal cancer is 80%", "correct": false}, {"label": "C", "text": "Amsterdam and Bethesda criteria can be used to diagnose Lynch syndrome", "correct": false}, {"label": "D", "text": "The most common site involved in cancer formation is the distal colon in Lynch syndrome", "correct": true}], "correct_answer": "D. The most common site involved in cancer formation is the distal colon in Lynch syndrome", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) The most common site involved in cancer formation is the distal colon in Lynch syndrome.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: Correct , Lynch syndrome is indeed an autosomal dominant condition.</li><li>• Option A: Correct</li><li>• Option B: Correct , the lifetime risk of developing colorectal cancer in Lynch syndrome is around 80%.</li><li>• Option B: Correct</li><li>• Option C: Correct , the Amsterdam and Bethesda criteria are a set of guidelines used to identify individuals who should be further tested for Lynch syndrome.</li><li>• Option C: Correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The proximal colon is the most common site of cancer formation in Lynch syndrome , contrasting with the misconception that the distal colon is predominantly affected .</li><li>➤ proximal colon</li><li>➤ most common site of cancer formation</li><li>➤ Lynch syndrome</li><li>➤ contrasting with the misconception</li><li>➤ distal colon is predominantly affected</li><li>➤ The lifetime risk is 80%. Most cancers develop in the proximal colon . Females have a 30-50% lifetime risk of developing endometrial cancer. Lynch syndrome was historically diagnosed based on a family history of cancer and the clinical parameters set out in the Amsterdam and Bethesda criteria. Recent advances in immunohistochemistry allow for MMR proteins or MSI to be accurately identified in all colorectal tumors with subsequent genetic testing in patients and families of those proven positive. Because of the accelerated pathway from adenoma to cancer in Lynch syndrome those with a gene mutation should be offered 2-yearly endoscopic surveillance from age 25 years (MLH1 and MSH2 carriers) or 35 years (MSH6 carriers). PMS2 carriers should be offered 5-yearly screening beginning at age 35 years</li><li>➤ The lifetime risk is 80%. Most cancers develop in the proximal colon . Females have a 30-50% lifetime risk of developing endometrial cancer.</li><li>➤ The lifetime risk is 80%. Most cancers develop in the proximal colon . Females have a 30-50% lifetime risk of developing endometrial cancer.</li><li>➤ Most cancers develop in the proximal colon</li><li>➤ Lynch syndrome was historically diagnosed based on a family history of cancer and the clinical parameters set out in the Amsterdam and Bethesda criteria.</li><li>➤ Lynch syndrome was historically diagnosed based on a family history of cancer and the clinical parameters set out in the Amsterdam and Bethesda criteria.</li><li>➤ Recent advances in immunohistochemistry allow for MMR proteins or MSI to be accurately identified in all colorectal tumors with subsequent genetic testing in patients and families of those proven positive.</li><li>➤ Recent advances in immunohistochemistry allow for MMR proteins or MSI to be accurately identified in all colorectal tumors with subsequent genetic testing in patients and families of those proven positive.</li><li>➤ immunohistochemistry</li><li>➤ MMR proteins or MSI</li><li>➤ Because of the accelerated pathway from adenoma to cancer in Lynch syndrome those with a gene mutation should be offered 2-yearly endoscopic surveillance from age 25 years (MLH1 and MSH2 carriers) or 35 years (MSH6 carriers).</li><li>➤ Because of the accelerated pathway from adenoma to cancer in Lynch syndrome those with a gene mutation should be offered 2-yearly endoscopic surveillance from age 25 years (MLH1 and MSH2 carriers) or 35 years (MSH6 carriers).</li><li>➤ PMS2 carriers should be offered 5-yearly screening beginning at age 35 years</li><li>➤ PMS2 carriers should be offered 5-yearly screening beginning at age 35 years</li><li>➤ Ref : Bailey and Love, 28 th Ed Pg 1358</li><li>➤ Ref : Bailey and Love, 28 th Ed Pg 1358</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In the context of colorectal cancer progression, which gene mutation is recognized as a marker indicative of the transition from a benign polyp to an invasive carcinoma?", "options": [{"label": "A", "text": "P53", "correct": true}, {"label": "B", "text": "RB gene", "correct": false}, {"label": "C", "text": "KRAS gene", "correct": false}, {"label": "D", "text": "APC gene", "correct": false}], "correct_answer": "A. P53", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) P53</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option B:</li><li>• RB gene</li><li>• retinoblastoma and other cancers</li><li>• Option C: The KRAS gene mutation plays a role in the earlier stages of colorectal cancer progression but is not as definitive for invasion as P53.</li><li>• Option C:</li><li>• KRAS gene mutation</li><li>• earlier stages of colorectal cancer progression</li><li>• Option D: The APC gene mutation occurs early in the adenoma-carcinoma sequence and is not a marker of invasion.</li><li>• Option D:</li><li>• APC gene mutation</li><li>• early in the adenoma-carcinoma sequence</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The P53 gene mutation is frequently associated with the invasive phase of colorectal cancer , distinguishing it from earlier mutations such as APC and KRAS which occur in pre-invasive lesions .</li><li>➤ P53 gene mutation</li><li>➤ invasive phase of colorectal cancer</li><li>➤ earlier mutations such as APC and KRAS</li><li>➤ pre-invasive lesions</li><li>➤ Mutations of the APC gene occur in two-thirds of colonic adenomas and are thought to develop early in the carcinogenesis pathway. K-ras mutations result in the activation of cell signaling pathways and are more common in larger lesions, suggesting that they are later events in mutagenesis. The p53 gene is frequently mutated in carcinomas but not in adenomas and therefore thought to be a marker of invasion. Mnemonic: Order of mutations: APC-&gt;K-ras-&gt;p53 = AK53</li><li>➤ Mutations of the APC gene occur in two-thirds of colonic adenomas and are thought to develop early in the carcinogenesis pathway.</li><li>➤ APC gene</li><li>➤ occur in two-thirds</li><li>➤ K-ras mutations result in the activation of cell signaling pathways and are more common in larger lesions, suggesting that they are later events in mutagenesis.</li><li>➤ K-ras</li><li>➤ The p53 gene is frequently mutated in carcinomas but not in adenomas and therefore thought to be a marker of invasion.</li><li>➤ The p53 gene is frequently mutated in carcinomas but not in adenomas and therefore thought to be a marker of invasion.</li><li>➤ Mnemonic: Order of mutations: APC-&gt;K-ras-&gt;p53 = AK53</li><li>➤ Mnemonic:</li><li>➤ Ref: Bailey and Love 28 th ed., Pg. 1358</li><li>➤ Ref: Bailey and Love 28 th ed., Pg. 1358</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "The second most common site of hematogenous metastasis in colorectal cancer is?", "options": [{"label": "A", "text": "Lungs", "correct": true}, {"label": "B", "text": "Liver", "correct": false}, {"label": "C", "text": "Brain", "correct": false}, {"label": "D", "text": "Ovaries", "correct": false}], "correct_answer": "A. Lungs", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Lungs</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The lungs are the second most common site of hematogenous metastases in colorectal cancer following the liver.</li><li>➤ lungs are the second most common site of hematogenous metastases in colorectal cancer</li><li>➤ Lung is the second most common site of metastasis after the liver .</li><li>➤ Lung is the second most common site of metastasis after the liver .</li><li>➤ Lung is the second most common site of metastasis after the liver</li><li>➤ Haematogenous spread is most commonly to the liver via the portal vein . One-third of patients will have liver metastases at the time of diagnosis and 50% will develop metastases at some point, accounting for the majority of deaths. The lung is the next most common site of metastatic disease whereas spread to the ovaries, brain, kidney and bone is less common.</li><li>➤ Haematogenous spread is most commonly to the liver via the portal vein . One-third of patients will have liver metastases at the time of diagnosis and 50% will develop metastases at some point, accounting for the majority of deaths. The lung is the next most common site of metastatic disease whereas spread to the ovaries, brain, kidney and bone is less common.</li><li>➤ liver via the portal vein</li><li>➤ The lung is the next most common site of metastatic disease</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 1359</li><li>➤ Ref:</li><li>➤ Bailey and Love, 28 th Ed. Pg 1359</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 55-year-old male presented to the OPD with recent changes in bowel habits, weight loss, and pallor. On colonoscopy with biopsy, rectal cancer was diagnosed. The biopsy showed that the muscularis propria was breached. According to Duke’s criteria, which stage would you place him at?", "options": [{"label": "A", "text": "Stage A", "correct": false}, {"label": "B", "text": "Stage B", "correct": true}, {"label": "C", "text": "Stage C", "correct": false}, {"label": "D", "text": "Stage D", "correct": false}], "correct_answer": "B. Stage B", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Stage B</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: Stage A is characterized by invasion into mucosa and submucosa</li><li>• Option A: Stage A</li><li>• invasion into mucosa and submucosa</li><li>• Option C: Stage C indicates that lymph nodes are involved , which is not mentioned in this case.</li><li>• Option C: Stage C</li><li>• lymph nodes are involved</li><li>• Option D: Stage D , although not originally described by Dukes, is commonly used to denote metastatic disease .</li><li>• Option D: Stage D</li><li>• commonly used to denote metastatic disease</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Colorectal cancer breaching the muscularis propria without lymph node involvement is classified as Duke's stage B .</li><li>➤ Colorectal cancer breaching</li><li>➤ muscularis propria without lymph node involvement</li><li>➤ Duke's stage B</li><li>➤ Dukes’ staging for colorectal cancer.</li><li>➤ Dukes’ staging for colorectal cancer.</li><li>➤ A: Invasion of but not breaching the muscularis propria B: Breaching the muscularis propria but not involving lymph nodes C: Lymph nodes involved</li><li>➤ A: Invasion of but not breaching the muscularis propria</li><li>➤ A:</li><li>➤ B: Breaching the muscularis propria but not involving lymph nodes</li><li>➤ B:</li><li>➤ C: Lymph nodes involved</li><li>➤ C:</li><li>➤ NOTE: Dukes himself never described a stage D, but this is often used to describe metastatic disease</li><li>➤ NOTE:</li><li>➤ Ref : Bailey and Love, 28th Ed. 1359</li><li>➤ Ref : Bailey and Love, 28th Ed. 1359</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "According to 8th AJCC classification of colorectal cancers, tumor deposits in the visceral peritoneum is staged as?", "options": [{"label": "A", "text": "T4a", "correct": true}, {"label": "B", "text": "N2b", "correct": false}, {"label": "C", "text": "T4b", "correct": false}, {"label": "D", "text": "M1c", "correct": false}], "correct_answer": "A. T4a", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/28/screenshot-2024-03-28-163710.jpg"], "explanation": "<p><strong>Ans. A) T4a</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Tumor deposits in the visceral peritoneum are classified as T4a in the AJCC 8th edition staging system for colorectal cancer.</li><li>➤ Tumor deposits</li><li>➤ visceral peritoneum</li><li>➤ T4a in the AJCC 8th edition staging system for colorectal cancer.</li><li>➤ Ref: Bailey and Love 28 th Ed., Pg. 1360</li><li>➤ Ref: Bailey and Love 28 th Ed., Pg. 1360</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the incorrect statement concerning MYH-Associated Polyposis (MAP).", "options": [{"label": "A", "text": "It’s an autosomal dominant condition", "correct": true}, {"label": "B", "text": "MAP is considered a diagnosis if the APC variant is not identified", "correct": false}, {"label": "C", "text": "Colonoscopy should be performed every 2 years", "correct": false}, {"label": "D", "text": "Surveillance for duodenal adenomas should also be done", "correct": false}], "correct_answer": "A. It’s an autosomal dominant condition", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) It’s an autosomal dominant condition</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option B: Correct , if no APC pathogenic variant is identified in a polyposis patient, MAP should be considered, and MUTYH gene testing is indicated.</li><li>• Option B:</li><li>• Correct</li><li>• Option C: Correct , individuals with MAP should undergo colonoscopic surveillance every 2 years.</li><li>• Option C:</li><li>• Correct</li><li>• Option D: Correct , surveillance for duodenal adenomas is also recommended in individuals with MAP.</li><li>• Option D:</li><li>• Correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ MYH-Associated Polyposis (MAP) is an autosomal recessive condition , not autosomal dominant , which is characterized by a predisposition to multiple colonic polyps and an associated increased risk for colorectal cancer .</li><li>➤ MYH-Associated Polyposis</li><li>➤ autosomal recessive condition</li><li>➤ not autosomal dominant</li><li>➤ predisposition to multiple colonic polyps</li><li>➤ increased risk for colorectal cancer</li><li>➤ If an APC pathogenic variant is not identified in an individual with colonic polyposis, molecular genetic testing of MUTYH should be considered. There is an increased risk of colorectal cancer of between three and six-fold depending on the particular MUTYH mutation. Colonoscopy should be performed every 2 years . Colectomy is required when the number and/or characteristics of the polyps do not allow complete endoscopic resection or malignancy is diagnosed. Surveillance for duodenal adenomas is recommended.</li><li>➤ If an APC pathogenic variant is not identified in an individual with colonic polyposis, molecular genetic testing of MUTYH should be considered. There is an increased risk of colorectal cancer of between three and six-fold depending on the particular MUTYH mutation.</li><li>➤ MUTYH</li><li>➤ Colonoscopy should be performed every 2 years .</li><li>➤ Colonoscopy should be performed every 2 years</li><li>➤ Colectomy is required when the number and/or characteristics of the polyps do not allow complete endoscopic resection or malignancy is diagnosed. Surveillance for duodenal adenomas is recommended.</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg. 1357</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg. 1357</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 30-year-old patient presented with tenesmus and rectal bleeding. On endoscopy, the following picture was obtained. What is the FALSE statement concerning the above condition?", "options": [{"label": "A", "text": "This disease begins at the rectum and moves proximally", "correct": false}, {"label": "B", "text": "Smoking is a risk factor", "correct": true}, {"label": "C", "text": "The fulminant disease is characterized by more than 10 bowel movements in a day", "correct": false}, {"label": "D", "text": "The disease is limited to mucosa and submucosa only", "correct": false}], "correct_answer": "B. Smoking is a risk factor", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/28/picture6_n0NHWfP.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B) Smoking is a risk factor.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: The characteristic pattern of inflammation in ulcerative colitis begins at the rectum and typically extends proximally in a continuous manner .</li><li>• Option A:</li><li>• pattern of inflammation in ulcerative colitis</li><li>• rectum</li><li>• proximally in a continuous manner</li><li>• Option C: Fulminant colitis , a severe form of ulcerative colitis , can present with more than 10 bowel movements per day , often with systemic symptoms and a risk of toxic megacolon.</li><li>• Option C: Fulminant colitis</li><li>• severe form of ulcerative colitis</li><li>• more than 10 bowel movements per day</li><li>• Option D: Ulcerative colitis affects only the mucosal and submucosal layers of the colon , which differentiates it from Crohn's disease that can involve the entire thickness of the bowel wall.</li><li>• Option D: Ulcerative colitis</li><li>• mucosal and submucosal layers of the colon</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Smoking is not a risk factor for ulcerative colitis ; it is, in fact, inversely associated, with a protective effect reported in some studies.</li><li>➤ Smoking</li><li>➤ not a risk factor for ulcerative colitis</li><li>➤ UC is characterised by mucosal inflammation of the large bowel , always involving the rectum (proctitis) and extending to involve varying degrees of more proximal colon (colitis). When the entire colon and rectum are involved (pancolitis), some patients may also have a degree of ‘backwash ileitis’ , in which there is secondary inflammation in the terminal ileum.</li><li>➤ UC is characterised by mucosal inflammation of the large bowel , always involving the rectum (proctitis) and extending to involve varying degrees of more proximal colon (colitis). When the entire colon and rectum are involved (pancolitis), some patients may also have a degree of ‘backwash ileitis’ , in which there is secondary inflammation in the terminal ileum.</li><li>➤ UC is characterised by mucosal inflammation of the large bowel , always involving the rectum (proctitis) and extending to involve varying degrees of more proximal colon (colitis). When the entire colon and rectum are involved (pancolitis), some patients may also have a degree of ‘backwash ileitis’ , in which there is secondary inflammation in the terminal ileum.</li><li>➤ UC is characterised by mucosal inflammation of the large bowel</li><li>➤ involving the rectum</li><li>➤ extending to involve varying degrees of more proximal colon</li><li>➤ ‘backwash ileitis’</li><li>➤ Truelove and Witt severity of UC:</li><li>➤ Truelove and Witt severity of UC:</li><li>➤ Mild &lt;4 stools/day, Moderate 4 to 6/day, no systemic illness Severe &gt; 6 stools/d, hypoalbuminemia, systemic illness Fulminant &gt;10/d, toxic megacolon</li><li>➤ Mild &lt;4 stools/day, Moderate 4 to 6/day, no systemic illness</li><li>➤ Mild &lt;4 stools/day, Moderate 4 to 6/day, no systemic illness</li><li>➤ Severe &gt; 6 stools/d, hypoalbuminemia, systemic illness</li><li>➤ Severe &gt; 6 stools/d, hypoalbuminemia, systemic illness</li><li>➤ Fulminant &gt;10/d, toxic megacolon</li><li>➤ Fulminant &gt;10/d, toxic megacolon</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg. 1319</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg. 1319</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the incorrect statement of colorectal cancers.", "options": [{"label": "A", "text": "Screening test of choice is flexible colonoscopy", "correct": true}, {"label": "B", "text": "Current protocols for colonic surgery permit the use of preoperative bowel preparation", "correct": false}, {"label": "C", "text": "The most important determinant of prognosis is tumor stage", "correct": false}, {"label": "D", "text": "Liver metastasis may be resectable", "correct": false}], "correct_answer": "A. Screening test of choice is flexible colonoscopy", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Screening test of choice is flexible colonoscopy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option B: There is evidence that preoperative mechanical bowel preparation in combination with preoperative oral antibiotics not only reduces surgical site infection rates but also rates of anastomotic leak, postoperative ileus, reoperation and even mortality.</li><li>• Option B:</li><li>• preoperative mechanical bowel preparation</li><li>• preoperative oral antibiotics</li><li>• Option C: Overall, 5-year survival for colorectal cancer is approximately 58%. While numerous factors may predict prognosis the most important determinant is tumour stage and, in particular, lymph node status . Patients with disease confined to the bowel wall (TNM stage 1, Dukes’ stage A) will usually have a cure by surgical resection alone and around 95% will have disease-free survival at 5 years.</li><li>• Option C:</li><li>• most important determinant is tumour stage and, in particular, lymph node status</li><li>• Option D: Hepatic and pulmonary metastases can be resected and series have demonstrated 5-year survival of around 40% in resectable disease. CT, MRI and positron emission tomography (PET) scanning are all used to identify colorectal metastases and assess patients’ suitability for further resection.</li><li>• Option D:</li><li>• Hepatic and pulmonary metastases</li><li>• resected and series have demonstrated 5-year survival of around 40% in resectable disease.</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• The key incorrect statement regarding colorectal cancer is that flexible colonoscopy is the screening test of choice . In fact, screening in the UK involves a fecal immunochemical test (FIT) offered biennially to specific age groups, with colonoscopy following a positive FIT result .</li><li>• incorrect statement regarding colorectal cancer</li><li>• flexible colonoscopy</li><li>• screening test of choice</li><li>• screening in the UK involves a fecal immunochemical test</li><li>• colonoscopy following a positive FIT result</li><li>• Ref : Bailey and Love, 28 th Ed. Pg 1360, 1363, 1364.</li><li>• Ref : Bailey and Love, 28 th Ed. Pg 1360, 1363, 1364.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 19-year-old patient was brought to the casualty with a high fever and pain in the abdomen. He had a history of bloody diarrhea for several months. The abdominal X-ray image obtained is shown below. What is the most probable diagnosis?", "options": [{"label": "A", "text": "Intestinal perforation", "correct": false}, {"label": "B", "text": "Toxic megacolon", "correct": true}, {"label": "C", "text": "Pneumatosis intestinalis", "correct": false}, {"label": "D", "text": "Sigmoid volvulus", "correct": false}], "correct_answer": "B. Toxic megacolon", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/28/picture7_SaCqQUI.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B) Toxic megacolon</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: Intestinal perforation</li><li>• serious complication of several abdominal conditions,</li><li>• acute onset of severe abdominal pain</li><li>• Option C: Pneumatosis intestinalis presents with multiple air pockets within the wall of the intestine on imaging , which is not described here.</li><li>• Option C: Pneumatosis intestinalis</li><li>• multiple air pockets</li><li>• wall of the intestine on imaging</li><li>• Option D: Sigmoid volvulus would show a distinctive twisted loop of bowel on imaging and is less likely in a patient with a history of inflammatory bowel disease.</li><li>• Option D: Sigmoid volvulus</li><li>• distinctive twisted loop of bowel</li><li>• imaging</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective :</li><li>➤ It is important to understand the clinical and radiographic signs of toxic megacolon which a severe complication of ulcerative colitis is characterized by colonic dilation , abdominal pain , and systemic symptoms .</li><li>➤ clinical and radiographic signs of toxic megacolon</li><li>➤ severe complication of ulcerative colitis</li><li>➤ colonic dilation</li><li>➤ abdominal pain</li><li>➤ systemic symptoms</li><li>➤ Approximately 5% of patients present with acute severe (fulminant) colitis. Intensive medical treatment leads to remission in 70% but the remainder require urgent surgery. Toxic dilatation should be suspected in patients who develop severe abdominal pain and confirmed by the presence on a plain abdominal radiograph of a colon with a diameter of more than 6 cm . Colonic perforation is a grave complication with a mortality rate of 40%. Steroids may mask the physical signs</li><li>➤ Approximately 5% of patients present with acute severe (fulminant) colitis. Intensive medical treatment leads to remission in 70% but the remainder require urgent surgery. Toxic dilatation should be suspected in patients who develop severe abdominal pain and confirmed by the presence on a plain abdominal radiograph of a colon with a diameter of more than 6 cm .</li><li>➤ Approximately 5% of patients present with acute severe (fulminant) colitis. Intensive medical treatment leads to remission in 70% but the remainder require urgent surgery. Toxic dilatation should be suspected in patients who develop severe abdominal pain and confirmed by the presence on a plain abdominal radiograph of a colon with a diameter of more than 6 cm .</li><li>➤ diameter of more than 6 cm</li><li>➤ Colonic perforation is a grave complication with a mortality rate of 40%. Steroids may mask the physical signs</li><li>➤ Colonic perforation is a grave complication with a mortality rate of 40%. Steroids may mask the physical signs</li><li>➤ Colonic perforation</li><li>➤ Steroids may mask the physical signs</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1320.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1320.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "What is the most common extra intestinal manifestation of ulcerative colitis?", "options": [{"label": "A", "text": "Erythema nodosum", "correct": false}, {"label": "B", "text": "Arthropathy", "correct": true}, {"label": "C", "text": "Primary sclerosing cholangitis", "correct": false}, {"label": "D", "text": "Pyoderma gangrenosum", "correct": false}], "correct_answer": "B. Arthropathy", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Arthropathy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: Erythema nodosum is a condition that presents as red and painful nodules on the skin , particularly on the shins, and is one of the skin manifestations associated with ulcerative colitis.</li><li>• Option A:</li><li>• Erythema nodosum</li><li>• presents as red and painful nodules on the skin</li><li>• Option B: Arthropathy in the context of UC often refers to joint pain or swelling , which can be a manifestation of conditions like sacroiliitis or ankylosing spondylitis, which are more common in UC than the other listed conditions.</li><li>• Option B:</li><li>• Arthropathy</li><li>• refers to joint pain or swelling</li><li>• sacroiliitis or ankylosing spondylitis,</li><li>• Option C: Primary sclerosing cholangitis is a serious liver condition that can be associated with UC but is not as common as joint issues . It leads to inflammation and scarring of the bile ducts.</li><li>• Option C:</li><li>• Primary sclerosing cholangitis</li><li>• serious liver condition</li><li>• UC but is not as common as joint issues</li><li>• Option D: Pyoderma gangrenosum is a rare skin disorder characterized by painful ulcers, typically more uncommon than arthropathy in the context of UC.</li><li>• Option D:</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Arthropathy is the most frequent extra-intestinal manifestation of ulcerative colitis , affecting around 15% of patients.</li><li>➤ Arthropathy</li><li>➤ most frequent extra-intestinal manifestation of ulcerative colitis</li><li>➤ Other manifestations include:</li><li>➤ Other manifestations include:</li><li>➤ Skin: pyoderma gangrenosum, erythema nodosum Eyes: episcleritis, uveitis Primary sclerosing cholangitis</li><li>➤ Skin: pyoderma gangrenosum, erythema nodosum</li><li>➤ Skin: pyoderma gangrenosum, erythema nodosum</li><li>➤ Skin:</li><li>➤ Eyes: episcleritis, uveitis</li><li>➤ Eyes: episcleritis, uveitis</li><li>➤ Eyes:</li><li>➤ Primary sclerosing cholangitis</li><li>➤ Primary sclerosing cholangitis</li><li>➤ Note: Though cholangiocarcinoma is associated, the risk does not reduce after colectomy.</li><li>➤ Note:</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 1320</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 1320</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 60-year-old man presented with an episode of syncope. He said he felt dizzy during defecation and noticed gross bleeding in the pan. Screening done 2 months back was negative for colon cancer. There is no history of recent weight loss. What is the likely colonoscopic finding?", "options": [{"label": "A", "text": "Early-stage carcinoma colon", "correct": false}, {"label": "B", "text": "Sigmoid diverticulitis", "correct": false}, {"label": "C", "text": "Microscopic colitis", "correct": false}, {"label": "D", "text": "Dilated mucosal and submucosal veins in the colon", "correct": true}], "correct_answer": "D. Dilated mucosal and submucosal veins in the colon", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Dilated mucosal and submucosal veins in the colon</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option A: Early-stage carcinoma of the colon is typically associated with weight loss and changes in bowel habits but less likely with a negative recent colonoscopy.</li><li>• Option A:</li><li>• Early-stage carcinoma</li><li>• colon</li><li>• weight loss</li><li>• changes in bowel habits</li><li>• Option B: Sigmoid diverticulitis usually presents with left lower quadrant pain and fever , less commonly with significant bleeding unless complicated by perforation.</li><li>• Option B:</li><li>• Sigmoid diverticulitis</li><li>• left lower quadrant pain and fever</li><li>• Option C: Microscopic colitis typically presents with watery diarrhea without visible blood and is not associated with the described vascular malformation.</li><li>• Option C:</li><li>• Microscopic colitis</li><li>• watery diarrhea without visible blood</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In patients over the age of 60 , particularly those with aortic stenosis , angiodysplasia is a common cause of lower gastrointestinal bleeding and can be identified on colonoscopy as dilated tortuous submucosal veins , especially in the right colon.</li><li>➤ over the age of 60</li><li>➤ aortic stenosis</li><li>➤ angiodysplasia</li><li>➤ common cause of lower gastrointestinal bleeding</li><li>➤ colonoscopy</li><li>➤ dilated tortuous submucosal veins</li><li>➤ right colon.</li><li>➤ Angiodysplasia: Angiodysplasia is a vascular malformation that commonly causes hemorrhage from the colon in patients over the age of 60. The malformations consist of dilated tortuous submucosal veins .</li><li>➤ Angiodysplasia:</li><li>➤ The malformations consist of dilated tortuous submucosal veins</li><li>➤ Clinical features: In the majority of cases, the symptoms are subtle and patients can present with anemia. About 10–15% have brisk bleeds, which may present as melaena or significant rectal bleeding. Many patients in whom rectal bleeding has been attributed to diverticular disease have probably bled from angiodysplasia. There is an association with aortic stenosis (Heyde’s syndrome) .</li><li>➤ Clinical features:</li><li>➤ (Heyde’s syndrome)</li><li>➤ Investigation: Colonoscopy may show the characteristic lesion in the right colon. The lesions are only a few millimetres in size and appear as reddish, raised areas at endoscopy. CT angiography shows the site and extent of the lesion by a ‘blush’ of contrast, provided bleeding is more rapid than 1 mL/min .</li><li>➤ Investigation:</li><li>➤ reddish, raised areas</li><li>➤ bleeding is more rapid than 1 mL/min</li><li>➤ Management: CT angiography allows not only localization if bleeding is rapid but also therapeutic embolization . If angiography fails or is unavailable, careful colonoscopy (with copious lavage) may allow cauterisation to be carried out and an argon laser can be helpful. In severe uncontrolled bleeding, surgery becomes necessary.</li><li>➤ Management:</li><li>➤ therapeutic embolization</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 1370-71.</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 1370-71.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is incorrect about colonic diverticular disease?", "options": [{"label": "A", "text": "The most common site of diverticula is the rectum", "correct": true}, {"label": "B", "text": "Diverticula are usually an incidental diagnosis", "correct": false}, {"label": "C", "text": "Imaging like barium enema shows a “Saw-tooth” appearance", "correct": false}, {"label": "D", "text": "Pneumaturia occurs due to colo-vesical fistula", "correct": false}], "correct_answer": "A. The most common site of diverticula is the rectum", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/28/picture9_LsHyAkS.jpg"], "explanation": "<p><strong>Ans. A) The most common site of diverticula is the rectum</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanations:</li><li>• Option B: Diverticula are most often asymptomatic (diverticulosis) and found incidentally. but they can present clinically with sepsis or haemorrhage.</li><li>• Option B:</li><li>• Diverticula</li><li>• asymptomatic</li><li>• Option C: Diverticula appear as “Saw-tooth” on contrast imaging</li><li>• Option C:</li><li>• Diverticula</li><li>• “Saw-tooth”</li><li>• Option D: The presentation of a fistula resulting from diverticular disease depends on the site. The most common colo-vesical fistula results in recurrent urinary tract infections and pneumaturia (flatus in the urine) or even feces in the urine .</li><li>• Option D:</li><li>• fistula resulting from diverticular disease</li><li>• most common colo-vesical fistula</li><li>• recurrent urinary tract infections</li><li>• pneumaturia</li><li>• even feces in the urine</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Colonic diverticuli are acquired false diverticuli which commonly affect sigmoid colon and descending colon . Rectum is spared due to its thick muscular coat.</li><li>• Colonic diverticuli</li><li>• acquired false diverticuli</li><li>• sigmoid colon and descending colon</li><li>• Rectum</li><li>• thick muscular coat.</li><li>• Ref: Bailey and Love 28 th Ed. Pg 1368-69.</li><li>• Ref:</li><li>• Bailey and Love 28 th Ed. Pg 1368-69.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 60-year-old male presents with chronic progressive abdominal distension and recent onset hiccoughs. On inquiry, he is passing neither flatus nor stools. X-ray shows a dilated loop of bowel with two limbs running diagonally across the abdomen from right to left, with two fluid levels seen. What is the likely diagnosis?", "options": [{"label": "A", "text": "Caecal volvulus", "correct": false}, {"label": "B", "text": "Sigmoid volvulus", "correct": true}, {"label": "C", "text": "Gall stone ileus", "correct": false}, {"label": "D", "text": "Diverticular perforation", "correct": false}], "correct_answer": "B. Sigmoid volvulus", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture9.jpg"], "explanation": "<p><strong>Ans. B) Sigmoid volvulus</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Options A: Cecal volvulus: Shows single dilated cecal loop with “embryo sign ”</li><li>• Options A:</li><li>• Cecal volvulus:</li><li>• single dilated cecal loop with “embryo sign</li><li>• Option C: This is a rare condition characterised by Rigler’s triad of small bowel dilation , pneumobilia and calcified gall stone shadow in right iliac fossa.</li><li>• Option C:</li><li>• rare condition characterised by Rigler’s triad</li><li>• small bowel dilation</li><li>• pneumobilia</li><li>• Option D: This will present with free gas on X ray (pneumoperitoneum)</li><li>• Option D:</li><li>• free gas on X ray</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In sigmoid volvulus , a plain radiograph shows massive colonic distension . The classic appearance is of a dilated loop of bowel ; the two limbs are seen running diagonally across the abdomen from right to left with two fluid levels seen , one within each loop of bowel (if an erect film is taken).</li><li>➤ sigmoid volvulus</li><li>➤ plain radiograph shows massive colonic distension</li><li>➤ classic appearance is of a dilated loop of bowel</li><li>➤ two limbs are seen running diagonally</li><li>➤ abdomen from right to left with two fluid levels seen</li><li>➤ Volvulus: May involve the small intestine, caecum or sigmoid colon</li><li>➤ Volvulus:</li><li>➤ small intestine, caecum or sigmoid colon</li><li>➤ Neonatal midgut volvulus secondary to midgut malrotation is life-threatening The most common spontaneous type in adults is sigmoid volvulus Predisposing factors include a high-residue diet and constipation. In western populations, the condition is seen most often in elderly patients with chronic constipation; comorbidities are common and chronic psychotropic drug use is associated with this condition. Rotation nearly always occurs in the anticlockwise direction.</li><li>➤ Neonatal midgut volvulus secondary to midgut malrotation is life-threatening</li><li>➤ Neonatal midgut volvulus secondary to midgut malrotation is life-threatening</li><li>➤ The most common spontaneous type in adults is sigmoid volvulus</li><li>➤ The most common spontaneous type in adults is sigmoid volvulus</li><li>➤ most common spontaneous type in adults is sigmoid volvulus</li><li>➤ Predisposing factors include a high-residue diet and constipation. In western populations, the condition is seen most often in elderly patients with chronic constipation; comorbidities are common and chronic psychotropic drug use is associated with this condition.</li><li>➤ Predisposing factors include a high-residue diet and constipation. In western populations, the condition is seen most often in elderly patients with chronic constipation; comorbidities are common and chronic psychotropic drug use is associated with this condition.</li><li>➤ Rotation nearly always occurs in the anticlockwise direction.</li><li>➤ Rotation nearly always occurs in the anticlockwise direction.</li><li>➤ Presentation with volvulus can be classified as :</li><li>➤ Presentation with volvulus can be classified as</li><li>➤ Fulminant: sudden onset, severe pain, early vomiting, rapidly deteriorating clinical course; Indolent: insidious onset, slow progressive course, less pain, late vomiting.</li><li>➤ Fulminant: sudden onset, severe pain, early vomiting, rapidly deteriorating clinical course;</li><li>➤ Fulminant: sudden onset, severe pain, early vomiting, rapidly deteriorating clinical course;</li><li>➤ Fulminant:</li><li>➤ Indolent: insidious onset, slow progressive course, less pain, late vomiting.</li><li>➤ Indolent: insidious onset, slow progressive course, less pain, late vomiting.</li><li>➤ Indolent:</li></ul>\n<p><strong>References:</strong></p><ul><li>↳ Reference : Bailey and Love, 28 th Ed. Pg 1380, 1385.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 2-day-old child has still not passed meconium. The pediatrician makes a diagnosis of meconium ileus. Which of the following is incorrect about this condition?", "options": [{"label": "A", "text": "Cystic fibrosis is most often the associated finding", "correct": false}, {"label": "B", "text": "Meconium causes occlusion at DJ flexure", "correct": true}, {"label": "C", "text": "Barium enema is useful for diagnosis", "correct": false}, {"label": "D", "text": "Bishop Koop operation is used for treating meconium ileus", "correct": false}], "correct_answer": "B. Meconium causes occlusion at DJ flexure", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture6.jpg"], "explanation": "<p><strong>Ans. B) Meconium causes occlusion at DJ flexure</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Cystic is commonly associated. It leads to pancreatic exocrine insufficiency , leading to failure of digestion of meconium, forming meconium pellets which lead to obstruction at ileum.</li><li>• Option A:</li><li>• Cystic</li><li>• commonly associated.</li><li>• pancreatic exocrine insufficiency</li><li>• Option C: An abdominal radiograph may show a dilated small intestine with mottling . Fluid levels are generally not seen. The contrast enema shows an unused microcolon.</li><li>• Option C:</li><li>• abdominal radiograph</li><li>• dilated small intestine with mottling</li><li>• unused microcolon.</li><li>• Option D: The Bishop–Koop operation with its irrigating stoma is now rarely used . Various surgical procedures are used, including intestinal resection and temporary stoma formation, resection and primary anastomosis , and, in uncomplicated cases, enterotomy and irrigation of the bowel.</li><li>• Option D:</li><li>• Bishop–Koop operation</li><li>• irrigating stoma</li><li>• rarely used</li><li>• intestinal resection and temporary stoma formation,</li><li>• resection and primary anastomosis</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• The correct understanding and identification of the location of meconium obstruction and its associated conditions and treatment options are critical in pediatric surgical care. The goal is to accurately diagnose and manage meconium ileus , often associated with cystic fibrosis , and recognize that obstruction typically occurs at the terminal ileum , not the DJ flexure . Contrast enemas are used for diagnosis, but surgical interventions are reserved for cases complicated by factors such as atresia or volvulus.</li><li>• The goal is to accurately diagnose and manage meconium ileus</li><li>• cystic fibrosis</li><li>• obstruction</li><li>• occurs at the terminal ileum</li><li>• not the DJ flexure</li><li>• Uncomplicated meconium ileus may respond to treatment with a hyperosmolar Gastrografin enema ; this draws fluid into the gut lumen and also has detergent properties , which help to liquefy the meconium. Infants treated in this way need extra intravenous fluids to compensate for fluid shifts. Meconium ileus complicated by intestinal perforation, volvulus or atresia, or unresponsive to enemas, demands surgery.</li><li>• Uncomplicated meconium ileus may respond to treatment with a hyperosmolar Gastrografin enema ; this draws fluid into the gut lumen and also has detergent properties , which help to liquefy the meconium. Infants treated in this way need extra intravenous fluids to compensate for fluid shifts. Meconium ileus complicated by intestinal perforation, volvulus or atresia, or unresponsive to enemas, demands surgery.</li><li>• Uncomplicated meconium ileus</li><li>• hyperosmolar Gastrografin enema</li><li>• draws fluid into the gut lumen</li><li>• detergent properties</li><li>• Ref: Bailey and Love, 28 th Ed. Pg.1389</li><li>• Ref:</li><li>• Bailey and Love, 28 th Ed. Pg.1389</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of the following are true about paralytic ileus except?", "options": [{"label": "A", "text": "Bowel sounds will be hyperperistaltic", "correct": true}, {"label": "B", "text": "Colicky pain is not a feature of this condition", "correct": false}, {"label": "C", "text": "Elective abdominal surgery is the main cause", "correct": false}, {"label": "D", "text": "Supportive management is done for its management", "correct": false}], "correct_answer": "A. Bowel sounds will be hyperperistaltic", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Bowel sounds will be hyperperistaltic</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Correctly states that colicky pain is not a feature of paralytic ileus because it is characterized by a lack of bowel movement rather than intermittent, crampy pain.</li><li>• Option B: Correctly states</li><li>• colicky pain is not a feature of paralytic ileus</li><li>• lack of bowel movement</li><li>• Option C: True ; elective abdominal surgery is a common cause of paralytic ileus as it can disrupt the normal rhythmic contractions of the bowel.</li><li>• Option C:</li><li>• True</li><li>• Option D: True ; supportive management, including nasogastric decompression and electrolyte balance, is central to the management of paralytic ileus.</li><li>• Option D:</li><li>• True</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In paralytic ileus , bowel sounds are typically reduced or absent , not hyperperistaltic , due to impaired bowel motility.</li><li>➤ paralytic ileus</li><li>➤ bowel sounds</li><li>➤ reduced or absent</li><li>➤ not hyperperistaltic</li><li>➤ impaired bowel motility.</li><li>➤ A disruption of the normal propulsive ability of the intestine due to a malfunction of contractile activity in the absence of mechanical obstruction is known as ileus/ paralytic ileus .</li><li>➤ A disruption of the normal propulsive ability of the intestine due to a malfunction of contractile activity in the absence of mechanical obstruction is known as ileus/ paralytic ileus .</li><li>➤ A disruption of the normal propulsive ability of the intestine due to a malfunction of contractile activity in the absence of mechanical obstruction is known as ileus/ paralytic ileus .</li><li>➤ disruption of the normal propulsive ability of the intestine</li><li>➤ malfunction of contractile activity</li><li>➤ absence of mechanical obstruction</li><li>➤ ileus/ paralytic ileus</li><li>➤ Risk factors for ileus:</li><li>➤ Risk factors for ileus:</li><li>➤ Recent surgery: Postoperative ileus (typically 72 hours post op). Local inflammation (peritonitis, severe acute pancreatitis) Systemic inflammation by any cause, e.g., sepsis, trauma. Electrolyte disturbance (especially hypokalaemia and hypercalcemia). Acute endocrine disturbance (hypothyroidism, diabetic ketoacidosis). Medications, e.g., opioids Acute CNS disease (especially high spinal transections) Intestinal ischemia (mesenteric vascular disease)</li><li>➤ Recent surgery: Postoperative ileus (typically 72 hours post op).</li><li>➤ Recent surgery: Postoperative ileus (typically 72 hours post op).</li><li>➤ Recent surgery:</li><li>➤ Local inflammation (peritonitis, severe acute pancreatitis)</li><li>➤ Local inflammation (peritonitis, severe acute pancreatitis)</li><li>➤ Systemic inflammation by any cause, e.g., sepsis, trauma.</li><li>➤ Systemic inflammation by any cause, e.g., sepsis, trauma.</li><li>➤ Electrolyte disturbance (especially hypokalaemia and hypercalcemia).</li><li>➤ Electrolyte disturbance (especially hypokalaemia and hypercalcemia).</li><li>➤ Acute endocrine disturbance (hypothyroidism, diabetic ketoacidosis).</li><li>➤ Acute endocrine disturbance (hypothyroidism, diabetic ketoacidosis).</li><li>➤ Medications, e.g., opioids</li><li>➤ Medications, e.g., opioids</li><li>➤ opioids</li><li>➤ Acute CNS disease (especially high spinal transections)</li><li>➤ Acute CNS disease (especially high spinal transections)</li><li>➤ Intestinal ischemia (mesenteric vascular disease)</li><li>➤ Intestinal ischemia (mesenteric vascular disease)</li><li>➤ Clinical features:</li><li>➤ Clinical features:</li><li>➤ Symptoms include abdominal distension and vomiting. However, colicky pain is less of a feature. On examination, other than evidence of the cause, e.g. recent surgery, the abdomen will be distended, tympanic and have reduced or absent bowel sounds. Treatment: Ileus may be managed by nasogastric drainage and restriction of oral intake until there is evidence of improvement. Supportive care such as attention to fluid and electrolyte balance and nutrition is also important. The need for a laparotomy becomes increasingly likely the longer the bowel inactivity persists, particularly if it lasts for more than 7 days.</li><li>➤ Symptoms include abdominal distension and vomiting. However, colicky pain is less of a feature.</li><li>➤ Symptoms include abdominal distension and vomiting. However, colicky pain is less of a feature.</li><li>➤ On examination, other than evidence of the cause, e.g. recent surgery, the abdomen will be distended, tympanic and have reduced or absent bowel sounds.</li><li>➤ On examination, other than evidence of the cause, e.g. recent surgery, the abdomen will be distended, tympanic and have reduced or absent bowel sounds.</li><li>➤ Treatment: Ileus may be managed by nasogastric drainage and restriction of oral intake until there is evidence of improvement. Supportive care such as attention to fluid and electrolyte balance and nutrition is also important.</li><li>➤ Treatment: Ileus may be managed by nasogastric drainage and restriction of oral intake until there is evidence of improvement. Supportive care such as attention to fluid and electrolyte balance and nutrition is also important.</li><li>➤ Treatment:</li><li>➤ The need for a laparotomy becomes increasingly likely the longer the bowel inactivity persists, particularly if it lasts for more than 7 days.</li><li>➤ The need for a laparotomy becomes increasingly likely the longer the bowel inactivity persists, particularly if it lasts for more than 7 days.</li></ul>\n<p><strong>References:</strong></p><ul><li>↳ Reference: Bailey and Love, 28 th ed. Pg 1291-92</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 55 year old female came to the OPD with complaints of abdominal distention, vomiting, and constipation. X-ray findings are suggestive of large bowel obstruction. Which is the most common cause of colonic obstruction?", "options": [{"label": "A", "text": "Adhesions", "correct": false}, {"label": "B", "text": "Volvulus", "correct": false}, {"label": "C", "text": "Neoplasms", "correct": true}, {"label": "D", "text": "Hernia", "correct": false}], "correct_answer": "C. Neoplasms", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Neoplasms</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Adhesions , while a common cause of small bowel obstruction , are less frequently responsible for colonic obstruction . They typically result from previous surgeries or intraperitoneal inflammation.</li><li>• Option A:</li><li>• Adhesions</li><li>• common cause of small bowel obstruction</li><li>• colonic obstruction</li><li>• Option B: Volvulus , refers to the twisting of a part of the colon on itself . It can cause large bowel obstruction and is more commonly seen in specific sites such as the sigmoid colon or cecum.</li><li>• Option B:</li><li>• Volvulus</li><li>• twisting of a part of the colon on itself</li><li>• Option D: Hernia , can also be a cause of bowel obstruction if the hernial contents include parts of the colon , but it's not the most common cause for colonic obstruction specifically.</li><li>• Option D:</li><li>• Hernia</li><li>• cause of bowel obstruction if the hernial contents include parts of the colon</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Colonic neoplasms, including cancers , are the most common cause of colonic obstruction in adults , reflecting the importance of timely colorectal cancer screening.</li><li>➤ Colonic neoplasms,</li><li>➤ cancers</li><li>➤ most common cause of colonic obstruction</li><li>➤ adults</li></ul>\n<p><strong>References:</strong></p><ul><li>↳ Reference: Bailey and Love, 28 th Ed. Pg 1375</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the incorrect statement about intestinal strangulation.", "options": [{"label": "A", "text": "Venous blood flow is usually affected before arterial", "correct": false}, {"label": "B", "text": "Richter’s hernia strangulates without getting obstructed completely", "correct": false}, {"label": "C", "text": "Closed loop obstruction strangulates rapidly", "correct": false}, {"label": "D", "text": "In large bowel obstruction, splenic flexure is most prone to ischemia", "correct": true}], "correct_answer": "D. In large bowel obstruction, splenic flexure is most prone to ischemia", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) In large bowel obstruction, splenic flexure is most prone to ischemia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Venous blood flow usually affected before arterial : This is correct . In strangulation, the venous outflow is impeded before the arterial inflow, leading to congestion and increased pressure within the bowel segment, which can progress to ischemia.</li><li>• Option A:</li><li>• Venous blood flow</li><li>• usually affected before arterial</li><li>• correct</li><li>• Option B: Richter’s hernia strangulates without getting obstructed completely : This is also correct . A Richter's hernia involves only one sidewall of the bowel, which means it may strangulate without causing complete obstruction of the bowel lumen.</li><li>• Option B:</li><li>• Richter’s hernia strangulates without getting obstructed completely</li><li>• correct</li><li>• Option C: Closed loop obstruction strangulates rapidly : Correct . A closed-loop obstruction occurs when a segment of bowel is obstructed at two points, creating a \"closed loop.\" This is a surgical emergency as it can lead to rapid strangulation and necrosis of the affected bowel segment.</li><li>• Option C:</li><li>• Closed loop obstruction strangulates rapidly</li><li>• Correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In cases of intestinal strangulation , venous outflow obstruction precedes arterial inflow obstruction , Richter’s hernia can strangulate without complete bowel obstruction, closed-loop obstructions can strangulate rapidly , and in large bowel obstruction , the cecum is usually the segment most prone to ischemia, not the splenic flexure.</li><li>➤ intestinal strangulation</li><li>➤ venous outflow obstruction precedes arterial inflow obstruction</li><li>➤ Richter’s hernia</li><li>➤ strangulate without complete bowel obstruction,</li><li>➤ closed-loop obstructions</li><li>➤ strangulate rapidly</li><li>➤ large bowel obstruction</li><li>➤ Distension of the obstructed segment of the bowel results in high pressure within the bowel wall . This can happen when only part of the bowel wall is obstructed, as seen in a Richter’s hernia. Venous return is compromised before the arterial supply. The resultant increase in capillary pressure leads to impaired local perfusion and, once the arterial supply is impaired, hemorrhagic infarction occurs. As the viability of the bowel is compromised, translocation and systemic exposure to anaerobic organisms and endotoxin occurs. Localized tenderness indicates impending or established ischemia . The development of peritonism or peritonitis indicates impending or established infarction and/or perforation. In cases of large bowel obstruction, it is important to elicit these findings in the right iliac fossa as the caecum is most vulnerable to ischaemia . The presence of shock suggests underlying ischemia. In impending or established strangulation, pain is never completely absent. Generalized tenderness and the presence of rigidity indicate the need for early laparotomy. When pain persists despite conservative management, even in the absence of the above signs, strangulation should be presumed.</li><li>➤ Distension of the obstructed segment of the bowel results in high pressure within the bowel wall . This can happen when only part of the bowel wall is obstructed, as seen in a Richter’s hernia.</li><li>➤ Distension of the obstructed segment</li><li>➤ bowel</li><li>➤ high pressure within the bowel wall</li><li>➤ Venous return is compromised before the arterial supply. The resultant increase in capillary pressure leads to impaired local perfusion and, once the arterial supply is impaired, hemorrhagic infarction occurs. As the viability of the bowel is compromised, translocation and systemic exposure to anaerobic organisms and endotoxin occurs.</li><li>➤ Localized tenderness indicates impending or established ischemia . The development of peritonism or peritonitis indicates impending or established infarction and/or perforation. In cases of large bowel obstruction, it is important to elicit these findings in the right iliac fossa as the caecum is most vulnerable to ischaemia .</li><li>➤ Localized tenderness indicates impending or established ischemia</li><li>➤ the caecum is most vulnerable to ischaemia</li><li>➤ The presence of shock suggests underlying ischemia.</li><li>➤ In impending or established strangulation, pain is never completely absent.</li><li>➤ Generalized tenderness and the presence of rigidity indicate the need for early laparotomy.</li><li>➤ When pain persists despite conservative management, even in the absence of the above signs, strangulation should be presumed.</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 1379, 1382</li><li>➤ Ref:</li><li>➤ Bailey and Love, 28 th Ed. Pg 1379, 1382</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A child diagnosed with acute intussusception will show which characteristic sign on the USG scan?", "options": [{"label": "A", "text": "Claw sign", "correct": false}, {"label": "B", "text": "Doughnut sign", "correct": true}, {"label": "C", "text": "Single bubble sign", "correct": false}, {"label": "D", "text": "Sign of dance", "correct": false}], "correct_answer": "B. Doughnut sign", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture5.jpg"], "explanation": "<p><strong>Ans. B) Doughnut sign</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Claw sign is often used to describe the appearance of an intussuscepted bowel on a contrast enema .</li><li>• Option A: Claw sign</li><li>• describe the appearance of an intussuscepted bowel</li><li>• contrast enema</li><li>• Option C: Single bubble sign typically refers to an X-ray finding in infants with duodenal atresia , where a single large air bubble is visible due to a blockage.</li><li>• Option C:</li><li>• Single bubble sign</li><li>• X-ray finding in infants with duodenal atresia</li><li>• single large air bubble is visible</li><li>• Option D: Sign of Dance is associated with intussusception and refers to the palpable emptiness or lessened density in the right lower quadrant of the abdomen , which is usually occupied by the cecum.</li><li>• Option D:</li><li>• Sign of Dance</li><li>• intussusception</li><li>• palpable emptiness or lessened density</li><li>• right lower quadrant of the abdomen</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The imaging signs associated with intussusception on ultrasound , include the doughnut sign in the transverse section indicative of the presence of this condition.</li><li>➤ imaging signs associated with intussusception on ultrasound</li><li>➤ doughnut sign in the transverse section</li><li>➤ Abdominal ultrasonography has a high diagnostic sensitivity in children, demonstrating the typical doughnut appearance of concentric rings in the transverse section. Barium enema shows the “ Claw” sign. CT scanning is currently considered the most sensitive radiological method to confirm intussusception. The characteristic features of CT scan include a ‘target’ or ‘sausage’-shaped soft-tissue mass. In the infant with intussusception, after resuscitation with intravenous fluids, broad-spectrum antibiotics and nasogastric drainage is done. Non-operative reduction can be attempted using an air or barium enema. Successful reduction can only be accepted if there is free reflux of air or barium into the small bowel, together with resolution of symptoms and signs in the patient. Non-operative reduction is contraindicated if there are signs of peritonitis or perforation, there is a known pathological lead point or in the presence of profound shock. After reduction, the terminal part of the small bowel and the appendix will be seen to be bruised and oedematous. The viability of the whole bowel should be checked carefully. An irreducible intussusception or one complicated by infarction or a pathological lead point requires resection and primary anastomosis.</li><li>➤ Abdominal ultrasonography has a high diagnostic sensitivity in children, demonstrating the typical doughnut appearance of concentric rings in the transverse section. Barium enema shows the “ Claw” sign.</li><li>➤ Abdominal ultrasonography has a high diagnostic sensitivity in children, demonstrating the typical doughnut appearance of concentric rings in the transverse section. Barium enema shows the “ Claw” sign.</li><li>➤ typical doughnut appearance of concentric rings</li><li>➤ Claw” sign.</li><li>➤ CT scanning is currently considered the most sensitive radiological method to confirm intussusception. The characteristic features of CT scan include a ‘target’ or ‘sausage’-shaped soft-tissue mass.</li><li>➤ CT scanning is currently considered the most sensitive radiological method to confirm intussusception. The characteristic features of CT scan include a ‘target’ or ‘sausage’-shaped soft-tissue mass.</li><li>➤ ‘target’ or ‘sausage’-shaped soft-tissue mass.</li><li>➤ In the infant with intussusception, after resuscitation with intravenous fluids, broad-spectrum antibiotics and nasogastric drainage is done. Non-operative reduction can be attempted using an air or barium enema. Successful reduction can only be accepted if there is free reflux of air or barium into the small bowel, together with resolution of symptoms and signs in the patient.</li><li>➤ In the infant with intussusception, after resuscitation with intravenous fluids, broad-spectrum antibiotics and nasogastric drainage is done. Non-operative reduction can be attempted using an air or barium enema. Successful reduction can only be accepted if there is free reflux of air or barium into the small bowel, together with resolution of symptoms and signs in the patient.</li><li>➤ using an air or barium enema.</li><li>➤ Non-operative reduction is contraindicated if there are signs of peritonitis or perforation, there is a known pathological lead point or in the presence of profound shock.</li><li>➤ Non-operative reduction is contraindicated if there are signs of peritonitis or perforation, there is a known pathological lead point or in the presence of profound shock.</li><li>➤ pathological lead point</li><li>➤ After reduction, the terminal part of the small bowel and the appendix will be seen to be bruised and oedematous. The viability of the whole bowel should be checked carefully. An irreducible intussusception or one complicated by infarction or a pathological lead point requires resection and primary anastomosis.</li><li>➤ After reduction, the terminal part of the small bowel and the appendix will be seen to be bruised and oedematous. The viability of the whole bowel should be checked carefully. An irreducible intussusception or one complicated by infarction or a pathological lead point requires resection and primary anastomosis.</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 1385, 1388</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 1385, 1388</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "The procedure shown in the given image was done for which pathology in neonate:", "options": [{"label": "A", "text": "Necrotising enterocolitis", "correct": false}, {"label": "B", "text": "Hirschsprung disease", "correct": false}, {"label": "C", "text": "Meconium ileus", "correct": true}, {"label": "D", "text": "Intestinal atresia", "correct": false}], "correct_answer": "C. Meconium ileus", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture7.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Meconium ileus</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Necrotising enterocolitis is a serious condition in neonates characterized by inflammation and necrosis of the intestine . The Bishop-Koop procedure, shown in the image, is not typically performed for NEC. Management of NEC often involves bowel rest, antibiotics, and surgical intervention in severe cases.</li><li>• Option A:</li><li>• Necrotising enterocolitis</li><li>• serious condition in neonates</li><li>• inflammation and necrosis of the intestine</li><li>• Option B: Hirschsprung disease is a congenital condition where there's a lack of ganglion cells in the distal colon , leading to functional obstruction . The Bishop-Koop procedure is not performed for Hirschsprung disease. Surgical treatment for Hirschsprung disease typically involves removal of the affected portion of the colon and anastomosis.</li><li>• Option B:</li><li>• Hirschsprung disease</li><li>• congenital condition where there's a lack of ganglion cells in the distal colon</li><li>• functional obstruction</li><li>• Option D: Intestinal atresia is a congenital condition characterized by a narrowing or absence of a portion of the intestine. While surgery is necessary to correct intestinal atresia, the Bishop-Koop procedure is not specifically associated with this condition. Treatment typically involves resection of the affected segment and anastomosis.</li><li>• Option D:</li><li>• Intestinal atresia</li><li>• congenital condition characterized by a narrowing or absence of a portion of the intestine.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Bishop-Koop procedure , depicted in the image, is associated with the management of meconium ileus in neonates , facilitating bowel irrigation through an ileostomy .</li><li>➤ Bishop-Koop procedure</li><li>➤ associated with the management of meconium ileus in neonates</li><li>➤ bowel irrigation through an ileostomy</li><li>➤ Uncomplicated meconium ileus may respond to treatment with a hyperosmolar gastrografin enema; this draws fluid into the gut lumen and also has detergent properties, which help to liquefy the meconium. Infants treated in this way need extra intravenous fluids to compensate for fluid shifts. Meconium ileus complicated by intestinal perforation, volvulus or atresia, or unresponsive to enemas, demands surgery. Various surgical procedures are used, including intestinal resection and temporary stoma formation, resection and primary anastomosis, and, in uncomplicated cases, enterotomy and irrigation of the bowel. The Bishop–Koop operation with its irrigating stoma is now rarely used.</li><li>➤ Uncomplicated meconium ileus may respond to treatment with a hyperosmolar gastrografin enema; this draws fluid into the gut lumen and also has detergent properties, which help to liquefy the meconium. Infants treated in this way need extra intravenous fluids to compensate for fluid shifts. Meconium ileus complicated by intestinal perforation, volvulus or atresia, or unresponsive to enemas, demands surgery.</li><li>➤ Various surgical procedures are used, including intestinal resection and temporary stoma formation, resection and primary anastomosis, and, in uncomplicated cases, enterotomy and irrigation of the bowel. The Bishop–Koop operation with its irrigating stoma is now rarely used.</li></ul>\n<p><strong>References:</strong></p><ul><li>↳ Reference:</li><li>↳ Bailey and Love, 28 th Ed. Pg 1389</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Intravenous Neostigmine is used in treatment of:", "options": [{"label": "A", "text": "Recurrent adhesive obstruction", "correct": false}, {"label": "B", "text": "Ileo-colic intussusception", "correct": false}, {"label": "C", "text": "Meconium ileus", "correct": false}, {"label": "D", "text": "Colonic pseudo-obstruction", "correct": true}], "correct_answer": "D. Colonic pseudo-obstruction", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Colonic pseudo-obstruction</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Intravenous Neostigmine is not indicated for recurrent adhesive obstruction . Adhesive obstruction typically requires surgical intervention , such as adhesiolysis , rather than pharmacological treatment with Neostigmine.</li><li>• Option A:</li><li>• Intravenous Neostigmine</li><li>• not indicated for recurrent adhesive obstruction</li><li>• Adhesive obstruction</li><li>• surgical intervention</li><li>• adhesiolysis</li><li>• Option B: Management of intussusception often involves initial attempts at reduction with air or barium enema and surgical intervention if reduction is unsuccessful or if complications such as bowel ischemia occur.</li><li>• Option B:</li><li>• Management of intussusception</li><li>• initial attempts at reduction with air or barium enema</li><li>• surgical intervention if reduction is unsuccessful</li><li>• Option C: Neostigmine is not indicated for the treatment of meconium ileus . Management of meconium ileus typically involves supportive measures such as hydration, bowel rest, and the use of osmotic agents or mucolytics to help break down the meconium.</li><li>• Option C:</li><li>• Neostigmine</li><li>• not indicated for the treatment of meconium ileus</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Intravenous Neostigmine is used in the treatment of colonic pseudo-obstruction to promote colonic decompression and relieve symptoms.</li><li>➤ Intravenous Neostigmine</li><li>➤ used in the treatment of colonic pseudo-obstruction</li><li>➤ promote colonic decompression</li><li>➤ Colonic pseudo-obstruction</li><li>➤ Colonic pseudo-obstruction</li><li>➤ This may occur in an acute or a chronic form. The former, also known as Ogilvie’s syndrome , presents as acute large bowel obstruction. Abdominal radiographs show evidence of colonic obstruction, with marked caecal distension being a common feature. Indeed, caecal perforation is a well-recognized complication . The absence of a mechanical cause requires urgent confirmation by colonoscopy or a single-contrast water-soluble barium enema or CT.</li><li>➤ Ogilvie’s syndrome</li><li>➤ caecal perforation is a well-recognized complication</li><li>➤ Management:</li><li>➤ Management:</li><li>➤ Reversal of risk factors: Correct fluid and electrolyte imbalances, Stop or reduce offending drugs, e.g., opioids, anticholinergics, calcium channel blockers (where possible) Empty the rectum by enemas and/or flatus tube Endoscopic Colonoscopy +/– flatus tube decompression Pharmacological: Intravenous neostigmine unless decompression contraindicated (risk of arrhythmia and bronchospasms) Surgery Subtotal colectomy (usually with ileostomy), Venting stoma, e.g., cecostomy, in very unfit patients</li><li>➤ Reversal of risk factors: Correct fluid and electrolyte imbalances, Stop or reduce offending drugs, e.g., opioids, anticholinergics, calcium channel blockers (where possible)</li><li>➤ Reversal of risk factors:</li><li>➤ Empty the rectum by enemas and/or flatus tube Endoscopic Colonoscopy +/– flatus tube decompression</li><li>➤ Pharmacological: Intravenous neostigmine unless decompression contraindicated (risk of arrhythmia and bronchospasms)</li><li>➤ (risk of arrhythmia and bronchospasms)</li><li>➤ Surgery Subtotal colectomy (usually with ileostomy), Venting stoma, e.g., cecostomy, in very unfit patients</li><li>➤ Ref: Bailey and Love, 28 th Ed. pg 1392, 1294</li><li>➤ Ref:</li><li>➤ Bailey and Love, 28 th Ed. pg 1392, 1294</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50 years old patient underwent a hysterectomy for uterine fibroids, following which she developed post paralytic ileus. Which condition is responsible for paralytic ileus?", "options": [{"label": "A", "text": "Hypocalcemia", "correct": false}, {"label": "B", "text": "Hyponatremia", "correct": false}, {"label": "C", "text": "Hypokalemia", "correct": true}, {"label": "D", "text": "Hypernatremia", "correct": false}], "correct_answer": "C. Hypokalemia", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Hypokalemia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Hypocalcemia. While hypocalcemia can lead to various gastrointestinal symptoms such as abdominal cramps and diarrhea , it is not typically associated with the development of paralytic ileus. Instead, hypocalcemia may manifest with neuromuscular irritability, muscle spasms, and cardiac arrhythmias.</li><li>• Option A: Hypocalcemia.</li><li>• lead to various gastrointestinal symptoms such as abdominal cramps and diarrhea</li><li>• Option B: Hyponatremia. Although electrolyte imbalances can affect gastrointestinal motility , hyponatremia is not directly responsible for the development of paralytic ileus. Instead, severe hyponatremia can lead to neurological symptoms such as confusion, seizures, and coma.</li><li>• Option B: Hyponatremia.</li><li>• electrolyte imbalances</li><li>• affect gastrointestinal motility</li><li>• Option D: Hypernatremia. Similar to hyponatremia, hypernatremia is not directly responsible for causing paralytic ileus . Instead, hypernatremia can lead to symptoms such as thirst, confusion, and neurological deficits due to alterations in osmotic balance, but it does not typically affect gastrointestinal motility in a way that leads to ileus.</li><li>• Option D: Hypernatremia.</li><li>• hypernatremia is not directly responsible for causing paralytic ileus</li><li>• thirst, confusion, and neurological deficits</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ While electrolyte imbalances can impact gastrointestinal function , hypokalemia specifically is strongly associated with the development of paralytic ileus due to its role in regulating smooth muscle contraction in the intestine.</li><li>➤ electrolyte imbalances</li><li>➤ impact gastrointestinal function</li><li>➤ hypokalemia</li><li>➤ strongly associated with the development of paralytic ileus</li><li>➤ role in regulating smooth muscle contraction in the intestine.</li><li>➤ Paralytic ileus may be defined as a state in which there is failure of transmission of peristaltic waves secondary to neuromuscular failure (i.e., in the myenteric [Auerbach’s] and submucous [Meissner’s] plexuses) . The resultant stasis leads to accumulation of fluid and gas within the bowel, with associated distension, vomiting, absence of bowel sounds and absolute constipation. Hypokalemia is the most important contributing factor. Paralytic ileus takes on a clinical significance if, 72 hours after laparotomy: There has been no return of bowel sounds on auscultation; There has been no passage of flatus.</li><li>➤ Paralytic ileus may be defined as a state in which there is failure of transmission of peristaltic waves secondary to neuromuscular failure (i.e., in the myenteric [Auerbach’s] and submucous [Meissner’s] plexuses) . The resultant stasis leads to accumulation of fluid and gas within the bowel, with associated distension, vomiting, absence of bowel sounds and absolute constipation.</li><li>➤ Paralytic ileus may be defined as a state in which there is failure of transmission of peristaltic waves secondary to neuromuscular failure (i.e., in the myenteric [Auerbach’s] and submucous [Meissner’s] plexuses) . The resultant stasis leads to accumulation of fluid and gas within the bowel, with associated distension, vomiting, absence of bowel sounds and absolute constipation.</li><li>➤ failure of transmission of peristaltic waves secondary to neuromuscular failure</li><li>➤ myenteric [Auerbach’s] and submucous [Meissner’s] plexuses)</li><li>➤ Hypokalemia is the most important contributing factor.</li><li>➤ Hypokalemia is the most important contributing factor.</li><li>➤ Hypokalemia</li><li>➤ Paralytic ileus takes on a clinical significance if, 72 hours after laparotomy: There has been no return of bowel sounds on auscultation; There has been no passage of flatus.</li><li>➤ Paralytic ileus takes on a clinical significance if, 72 hours after laparotomy:</li><li>➤ Paralytic ileus</li><li>➤ There has been no return of bowel sounds on auscultation; There has been no passage of flatus.</li><li>➤ There has been no return of bowel sounds on auscultation;</li><li>➤ There has been no return of bowel sounds on auscultation;</li><li>➤ There has been no passage of flatus.</li><li>➤ There has been no passage of flatus.</li><li>➤ Paralytic ileus is managed with the use of nasogastric suction and restriction of oral intake until bowel sounds and the passage of flatus return . Electrolyte balance must be maintained.</li><li>➤ Paralytic ileus</li><li>➤ managed with the use of nasogastric suction</li><li>➤ restriction of oral intake</li><li>➤ bowel sounds and the passage of flatus return</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg. 1391</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg. 1391</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which vessel causes the maximum bowel gangrene in a patient with acute mesenteric ischemia?", "options": [{"label": "A", "text": "Inferior Mesenteric artery", "correct": false}, {"label": "B", "text": "Superior Mesenteric artery", "correct": true}, {"label": "C", "text": "Celiac trunk", "correct": false}, {"label": "D", "text": "Renal artery", "correct": false}], "correct_answer": "B. Superior Mesenteric artery", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Superior mesenteric artery</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: The Inferior Mesenteric artery primarily supplies blood to the distal portion of the large intestine. While occlusion of the Inferior Mesenteric artery can lead to ischemia in the sigmoid colon and rectum, it is less likely to cause significant damage compared to occlusion of the Superior Mesenteric artery due to collateral circulation.</li><li>• Option A:</li><li>• Inferior Mesenteric artery</li><li>• supplies blood to the distal portion of the large intestine.</li><li>• Option C: The Celiac trunk supplies blood to the upper abdominal organs , including the liver, stomach, and spleen . While occlusion of the Celiac trunk can lead to ischemia in these organs, it does not typically cause the severe bowel damage observed with occlusion of the Superior Mesenteric artery.</li><li>• Option C:</li><li>• Celiac trunk supplies blood to the upper abdominal organs</li><li>• liver, stomach, and spleen</li><li>• Option D: The Renal artery supplies blood to the kidneys , and occlusion of this artery can lead to renal ischemia and acute kidney injury . While renal ischemia is significant, it does not typically cause the extensive bowel damage observed with acute mesenteric ischemia.</li><li>• Option D:</li><li>• Renal artery supplies blood to the kidneys</li><li>• occlusion of this artery can lead to renal ischemia</li><li>• acute kidney injury</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Occlusion of the Superior Mesenteric artery is the most likely cause of significant damage in acute mesenteric ischemia due to its crucial role in supplying blood to the small intestine.</li><li>➤ Occlusion of the Superior Mesenteric artery</li><li>➤ cause of significant damage in acute mesenteric ischemia</li><li>➤ supplying blood to the small intestine.</li><li>➤ The superior mesenteric vessels are the visceral vessels most likely to be affected by embolization or thrombosis . Occlusion at the origin of the Superior Mesenteric artery is almost invariably the result of thrombosis , whereas emboli tend to lodge at the origin of the middle colic artery . Inferior mesenteric artery involvement is usually clinically silent because of a rich collateral circulation.</li><li>➤ The superior mesenteric vessels are the visceral vessels most likely to be affected by embolization or thrombosis . Occlusion at the origin of the Superior Mesenteric artery is almost invariably the result of thrombosis , whereas emboli tend to lodge at the origin of the middle colic artery . Inferior mesenteric artery involvement is usually clinically silent because of a rich collateral circulation.</li><li>➤ superior mesenteric vessels</li><li>➤ visceral vessels</li><li>➤ affected by embolization or thrombosis</li><li>➤ Occlusion</li><li>➤ origin of the Superior Mesenteric artery</li><li>➤ result of thrombosis</li><li>➤ emboli tend to lodge at the origin of the middle colic artery</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In Air-fluid level of acute intestinal obstruction, the air contains?", "options": [{"label": "A", "text": "CO2", "correct": false}, {"label": "B", "text": "Nitrogen", "correct": true}, {"label": "C", "text": "Methane", "correct": false}, {"label": "D", "text": "H2S", "correct": false}], "correct_answer": "B. Nitrogen", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Nitrogen</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: CO2 (Carbon dioxide) - While CO2 is a component of intestinal gas , it is rapidly absorbed into the bloodstream and is not the main component of the air seen in the bowel during obstruction.</li><li>• Option A: CO2 (Carbon dioxide) -</li><li>• component of intestinal gas</li><li>• rapidly absorbed into the bloodstream</li><li>• Option C: Methane - Some patients do produce methane ; however, it is not the predominant gas in the bowel during obstruction.</li><li>• Option C: Methane -</li><li>• produce methane</li><li>• Option D: H2S (Hydrogen sulfide) - This gas is produced in smaller amounts and is characterized by its foul odour . It is not the main component of gas in the bowel during an obstruction.</li><li>• Option D: H2S (Hydrogen sulfide) -</li><li>• produced in smaller amounts</li><li>• foul odour</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In the setting of acute intestinal obstruction , after the reabsorption of oxygen and carbon dioxide , nitrogen is the predominant gas remaining in the bowel , making up about 90% of the gas content .</li><li>➤ acute intestinal obstruction</li><li>➤ reabsorption of oxygen and carbon dioxide</li><li>➤ nitrogen</li><li>➤ gas remaining in the bowel</li><li>➤ 90% of the gas content</li><li>➤ The distension proximal to an obstruction is caused by two factors:</li><li>➤ The distension proximal to an obstruction is caused by two factors:</li><li>➤ Gas: there is a significant overgrowth of both aerobic and anaerobic organisms , resulting in considerable gas production. Following the reabsorption of oxygen and carbon dioxide, the majority is made up of nitrogen (90%) and hydrogen sulfide. Fluid: this is made up of the various digestive juices (saliva, 500 mL; bile, 500 mL; pancreatic secretions, 500 mL; gastric secretions, 1 litre; all per 24 hours). This accumulates in the gut lumen as absorption by the obstructed gut is retarded.</li><li>➤ Gas: there is a significant overgrowth of both aerobic and anaerobic organisms , resulting in considerable gas production. Following the reabsorption of oxygen and carbon dioxide, the majority is made up of nitrogen (90%) and hydrogen sulfide.</li><li>➤ Gas:</li><li>➤ overgrowth of both aerobic and anaerobic organisms</li><li>➤ gas production.</li><li>➤ Fluid: this is made up of the various digestive juices (saliva, 500 mL; bile, 500 mL; pancreatic secretions, 500 mL; gastric secretions, 1 litre; all per 24 hours). This accumulates in the gut lumen as absorption by the obstructed gut is retarded.</li><li>➤ Fluid:</li><li>➤ various digestive juices</li></ul>\n<p><strong>References:</strong></p><ul><li>↳ Reference:</li><li>↳ Bailey and Love, 28 th Ed. Pg 1375</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 20-year-old male presented to the casualty with acute abdominal pain, distention of the abdomen, and vomiting. On x-ray, the following characteristic pattern was noticed. What is the likely site of obstruction?", "options": [{"label": "A", "text": "Distal Duodenum", "correct": false}, {"label": "B", "text": "Distal Jejunum", "correct": true}, {"label": "C", "text": "Cecum", "correct": false}, {"label": "D", "text": "Rectum", "correct": false}], "correct_answer": "B. Distal Jejunum", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture1.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B) Distal Jejunum</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Duodenal obstruction is rare , and would not show dilated jejunum.</li><li>• Option A: Duodenal obstruction is rare</li><li>• Option C: The ileum is characterless on X-ray whereas a distended caecum appears as a rounded gas shadow in the right iliac fossa . As dilated ileum or cecum are not seen, the obstruction is not in the cecum.</li><li>• Option C:</li><li>• ileum is characterless on X-ray</li><li>• distended caecum appears as a rounded gas shadow in the right iliac fossa</li><li>• Option D: Rectal obstruction will show dilated colonic loops , which show typical “incomplete haustrations”.</li><li>• Option D: Rectal obstruction</li><li>• dilated colonic loops</li><li>• “incomplete haustrations”.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The correct identification of a jejunal obstruction on an abdominal X-ray is facilitated by recognizing the valvulae conniventes in the jejunum that create regular intervals of air-fluid levels across the width of the bowel .</li><li>➤ jejunal obstruction on an abdominal X-ray</li><li>➤ valvulae conniventes in the jejunum</li><li>➤ create regular intervals of air-fluid levels</li><li>➤ width of the bowel</li></ul>\n<p><strong>References:</strong></p><ul><li>↳ Reference: Bailey and Love 28 th edition Pg 1384</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A previously well 7-month-old male infant suddenly presents with episodes of screaming. The child appears pale and listless. The stools are red currant jelly-like. What is false regarding the above condition?", "options": [{"label": "A", "text": "There is an associated feeling of hardness over the Right iliac fossa.", "correct": true}, {"label": "B", "text": "Dehydration may occur if left untreated", "correct": false}, {"label": "C", "text": "Hyperplasia of Peyer’s patches may be a trigger", "correct": false}, {"label": "D", "text": "The most common type in children is ileocolic", "correct": false}], "correct_answer": "A. There is an associated feeling of hardness over the Right iliac fossa.", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) There is an associated feeling of hardness over the Right iliac fossa.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: \"Dehydration may occur if left untreated\" – This is true , as dehydration can occur due to vomiting and the sequestration of fluids into the bowel lumen in the setting of an intestinal obstruction like intussusception.</li><li>• Option B: \"Dehydration may occur if left untreated\" –</li><li>• true</li><li>• Option C: \"Hyperplasia of Peyer’s patches may be a trigger\" – This is also true . Hyperplasia of Peyer's patches in the terminal ileum can act as a lead point for intussusception, especially in infants and children following viral illnesses.</li><li>• Option C: \"Hyperplasia of Peyer’s patches may be a trigger\" –</li><li>• true</li><li>• Option D: \"Most common type is ileocolic\" – This is correct . The most common type of intussusception in children is ileocolic, where the ileum invaginates into the colon.</li><li>• Option D: \"Most common type is ileocolic\" –</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In intussusception , the feeling of hardness over the right iliac fossa is not a typical clinical sign ; instead, an associated feeling of emptiness , known as Dance's sign , may be present.</li><li>➤ intussusception</li><li>➤ feeling of hardness over the right iliac fossa</li><li>➤ not a typical clinical sign</li><li>➤ feeling of emptiness</li><li>➤ Dance's sign</li><li>➤ Intussusception: One portion of the gut invaginates into an immediately adjacent segment; almost invariably, it is the proximal into the distal .</li><li>➤ Intussusception:</li><li>➤ proximal into the distal</li><li>➤ Etiology: It is believed that hyperplasia of Peyer’s patches in the terminal ileum may be the initiating event. Weaning, loss of passively acquired maternal immunity, and common viral pathogens have all been implicated in the pathogenesis of intussusception in infancy.</li><li>➤ Etiology:</li><li>➤ hyperplasia of Peyer’s patches</li><li>➤ Parts:</li><li>➤ Parts:</li><li>➤ Outer bowel – intussuscipiens</li><li>➤ intussuscipiens</li><li>➤ Inner bowel - intussusceptum .</li><li>➤ intussusceptum</li><li>➤ Most prone to ischemia - Apex of intussusception .</li><li>➤ ischemia - Apex of intussusception</li><li>➤ Clinical Presentation:</li><li>➤ Clinical Presentation:</li><li>➤ The classic presentation of intussusception is with episodes of screaming and drawing up of the legs in a previously well male infant. The attacks last for a few minutes and recur repeatedly. During attacks the child appears pale and between episodes may be listless. Vomiting may or may not occur at the outset but becomes conspicuous and bile-stained with time. Initially, the passage of stool may be normal, whereas, later, blood and mucus are evacuated – the ‘red currant jelly’ stool . The abdomen is not initially distended; a lump that hardens on palpation may be discerned. There may be an associated feeling of emptiness in the right iliac fossa ( the sign of Dance ). On rectal examination, blood-stained mucus may be found on the finger. Dehydration is seen most commonly in small bowel obstruction because of repeated vomiting and fluid sequestration. It results in dry skin and tongue, poor venous filling and sunken eyes with oliguria. In most children, the intussusception is ileo-colic. In adults, colo-colic intussusception is more common.</li><li>➤ The classic presentation of intussusception is with episodes of screaming and drawing up of the legs in a previously well male infant.</li><li>➤ The classic presentation of intussusception is with episodes of screaming and drawing up of the legs in a previously well male infant.</li><li>➤ drawing up of the legs</li><li>➤ The attacks last for a few minutes and recur repeatedly. During attacks the child appears pale and between episodes may be listless. Vomiting may or may not occur at the outset but becomes conspicuous and bile-stained with time.</li><li>➤ The attacks last for a few minutes and recur repeatedly. During attacks the child appears pale and between episodes may be listless. Vomiting may or may not occur at the outset but becomes conspicuous and bile-stained with time.</li><li>➤ Initially, the passage of stool may be normal, whereas, later, blood and mucus are evacuated – the ‘red currant jelly’ stool .</li><li>➤ Initially, the passage of stool may be normal, whereas, later, blood and mucus are evacuated – the ‘red currant jelly’ stool .</li><li>➤ ‘red currant jelly’</li><li>➤ stool</li><li>➤ The abdomen is not initially distended; a lump that hardens on palpation may be discerned.</li><li>➤ The abdomen is not initially distended; a lump that hardens on palpation may be discerned.</li><li>➤ There may be an associated feeling of emptiness in the right iliac fossa ( the sign of Dance ). On rectal examination, blood-stained mucus may be found on the finger.</li><li>➤ There may be an associated feeling of emptiness in the right iliac fossa ( the sign of Dance ). On rectal examination, blood-stained mucus may be found on the finger.</li><li>➤ the sign of Dance</li><li>➤ Dehydration is seen most commonly in small bowel obstruction because of repeated vomiting and fluid sequestration. It results in dry skin and tongue, poor venous filling and sunken eyes with oliguria.</li><li>➤ Dehydration is seen most commonly in small bowel obstruction because of repeated vomiting and fluid sequestration. It results in dry skin and tongue, poor venous filling and sunken eyes with oliguria.</li><li>➤ In most children, the intussusception is ileo-colic. In adults, colo-colic intussusception is more common.</li><li>➤ In most children, the intussusception is ileo-colic. In adults, colo-colic intussusception is more common.</li><li>➤ In most children, the intussusception is ileo-colic. In adults, colo-colic intussusception is more common.</li></ul>\n<p><strong>References:</strong></p><ul><li>↳ Reference: Bailey and Love 28th ed., 1378-1382</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Four days after undergoing laparotomy for duodenal ulcer perforation, the patient is started on clear liquids. He complains of epigastric discomfort and bilious vomiting. Abdominal examination reveals generalized distension without tenderness and absent bowel sounds. All of these will be done next in management except?", "options": [{"label": "A", "text": "Stop orals and insert NG tube", "correct": false}, {"label": "B", "text": "Stop orals and feed via NJ tube", "correct": true}, {"label": "C", "text": "Serum Potassium levels", "correct": false}, {"label": "D", "text": "X ray of the abdomen", "correct": false}], "correct_answer": "B. Stop orals and feed via NJ tube", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Stop orals and feed via NJ tube</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Stopping oral intake and inserting a nasogastric (NG) tube is appropriate to decompress the stomach and prevent further vomiting and aspiration in cases of postoperative ileus.</li><li>• Option A:</li><li>• Stopping oral intake</li><li>• inserting a nasogastric</li><li>• tube</li><li>• decompress the stomach</li><li>• Option C: Checking serum potassium levels is important in the management of ileus , as electrolyte imbalances , particularly hypokalemia, can contribute to or worsen ileus.</li><li>• Option C:</li><li>• Checking serum potassium levels</li><li>• management of ileus</li><li>• electrolyte imbalances</li><li>• Option D: An abdominal X-ray is useful to assess for dilated bowel loops and to rule out other causes of abdominal distension such as mechanical obstruction.</li><li>• Option D:</li><li>• abdominal X-ray is useful to assess for dilated bowel loops</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In the management of postoperative ileus , it is important to stop oral intake and decompress the stomach with an NG tube , while monitoring and correcting electrolytes . Feeding via a nasojejunal (NJ) tube is not indicated at this stage and may exacerbate the ileus.</li><li>➤ management of postoperative ileus</li><li>➤ stop oral intake and decompress the stomach with an NG tube</li><li>➤ monitoring and correcting electrolytes</li></ul>\n<p><strong>References:</strong></p><ul><li>↳ Reference:</li><li>↳ Bailey and Love, 28 th Ed. Pg 1391</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient presented with acute abdominal pain and distention. The X-ray finding was as below. Beyond what diameter of small bowel distension is considered significant?", "options": [{"label": "A", "text": "2 cm", "correct": false}, {"label": "B", "text": "3 cm", "correct": true}, {"label": "C", "text": "4 cm", "correct": false}, {"label": "D", "text": "5 cm", "correct": false}], "correct_answer": "B. 3 cm", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture3.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture2.jpg"], "explanation": "<p><strong>Ans. B) 3 cm</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• The finding most specific for small bowel obstruction in plain X-ray imaging of the abdomen is the triad of the following:</li><li>• The finding most specific for small bowel obstruction in plain X-ray imaging of the abdomen is the triad of the following:</li><li>• Dilated small bowel loops (&gt;3 cm in diameter) Air-fluid levels seen on upright films Paucity of air in the colon</li><li>• Dilated small bowel loops (&gt;3 cm in diameter)</li><li>• (&gt;3 cm in diameter)</li><li>• Air-fluid levels seen on upright films</li><li>• Paucity of air in the colon</li><li>• In high small bowel obstruction , vomiting occurs early, is profuse and causes rapid dehydration. Distension is minimal with little evidence of dilated small bowel loops on abdominal radiography In low small bowel obstruction , pain is predominant with central distension. Vomiting occurs later. Multiple dilated small bowel loops are seen on radiography</li><li>• In high small bowel obstruction , vomiting occurs early, is profuse and causes rapid dehydration. Distension is minimal with little evidence of dilated small bowel loops on abdominal radiography</li><li>• high small bowel obstruction</li><li>• In low small bowel obstruction , pain is predominant with central distension. Vomiting occurs later. Multiple dilated small bowel loops are seen on radiography</li><li>• low small bowel obstruction</li><li>• The 3-6-9 rule is a simple aide-memoire describing the normal bowel calibre:</li><li>• 3-6-9 rule</li><li>• Small bowel: &lt;3 cm Large bowel: &lt;6 cm Appendix: &lt;6 mm Caecum: &lt;9 cm</li><li>• Small bowel: &lt;3 cm</li><li>• &lt;3 cm</li><li>• Large bowel: &lt;6 cm</li><li>• &lt;6 cm</li><li>• Appendix: &lt;6 mm</li><li>• &lt;6 mm</li><li>• Caecum: &lt;9 cm</li><li>• &lt;9 cm</li><li>• Above these dimensions, the bowel is generally considered dilated , and obstruction or an adynamic/paralytic ileus should be considered.</li><li>• bowel is generally considered dilated</li><li>• obstruction</li><li>• adynamic/paralytic ileus</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In assessing for small bowel obstruction , radiographic evidence of small bowel loops exceeding 3 cm in diameter is a key diagnostic criterion, typically warranting further clinical evaluation and management.</li><li>➤ assessing for small bowel obstruction</li><li>➤ radiographic evidence of small bowel loops</li><li>➤ 3 cm in diameter</li><li>➤ clinical evaluation and management.</li></ul>\n<p><strong>References:</strong></p><ul><li>↳ Reference:</li><li>↳ Bailey and Love 28 th edition, Pg. 1381</li><li>↳ Online ref: https://doi.org/10.53347/rID-66259</li><li>↳ Online ref:</li><li>↳ https://doi.org/10.53347/rID-66259</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 40-year-old female came to the OPD with complaints of abdominal distention, vomiting, and constipation. The findings given below were obtained on X-ray: What is the first symptom to manifest in such a condition?", "options": [{"label": "A", "text": "Vomiting", "correct": false}, {"label": "B", "text": "Constipation", "correct": false}, {"label": "C", "text": "Colicky pain", "correct": true}, {"label": "D", "text": "Abdominal distention", "correct": false}], "correct_answer": "C. Colicky pain", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture4.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Colicky pain</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Vomiting: While vomiting is a common symptom of intestinal obstruction , it generally occurs after pain due to the body's response to the obstruction.</li><li>• Option A. Vomiting:</li><li>• common symptom of intestinal obstruction</li><li>• Option B. Constipation: Constipation or failure to pass stool or gas is another symptom that follows pain and can indicate a blockage in the intestinal tract.</li><li>• Option B. Constipation:</li><li>• failure to pass stool or gas is another symptom</li><li>• Option D. Abdominal Distention: As the obstruction persists , gas and intestinal contents accumulate , leading to abdominal distention, which often presents after the onset of pain.</li><li>• Option D. Abdominal Distention:</li><li>• obstruction persists</li><li>• gas and intestinal contents accumulate</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In the clinical setting of intestinal obstruction, colicky pain is usually the earliest symptom due to increased peristaltic movements , followed by other symptoms such as vomiting, constipation, and abdominal distension as the obstruction progresses.</li><li>➤ colicky pain is usually the earliest symptom</li><li>➤ increased peristaltic movements</li><li>➤ vomiting, constipation, and abdominal distension</li><li>➤ obstruction progresses.</li></ul>\n<p><strong>References:</strong></p><ul><li>↳ Reference:</li><li>↳ Bailey and Love, 28 th Ed. Pg 1381</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 28-year-old male presents with colicky abdominal pain and bilious vomiting 3 years following an open appendectomy. Abdominal examination reveals hyper-peristalsis. X-ray abdomen showed the following. What is the likely pathology and the next step?", "options": [{"label": "A", "text": "Paralytic ileus - Put a NG tube", "correct": false}, {"label": "B", "text": "Paralytic ileus - CECT abdomen", "correct": false}, {"label": "C", "text": "Adhesive obstruction - CECT abdomen", "correct": true}, {"label": "D", "text": "Adhesive obstruction - laparotomy", "correct": false}], "correct_answer": "C. Adhesive obstruction - CECT abdomen", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture8.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Adhesive obstruction - CECT abdomen</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Paralytic ileus - Put a NG tube. Paralytic ileus is characterized by decreased bowel motility without mechanical obstruction . Patients typically present with decreased or absent bowel sounds and lack of peristalsis . Inserting a nasogastric (NG) tube for decompression may be indicated to relieve abdominal distension and vomiting. However, in this case, the presence of a step ladder pattern of air-fluid levels on X-ray suggests a mechanical obstruction rather than paralytic ileus. Therefore, while NG tube placement can be part of supportive care, it does not address the underlying cause of the obstruction.</li><li>• Option A:</li><li>• Paralytic ileus - Put a NG tube.</li><li>• decreased bowel motility without mechanical obstruction</li><li>• decreased or absent bowel sounds and lack of peristalsis</li><li>• Option B: Paralytic ileus - CECT abdomen. In this scenario, however, the X-ray findings indicate a mechanical obstruction with a step ladder pattern of air-fluid levels , which is not consistent with paralytic ileus.</li><li>• Option B:</li><li>• Paralytic ileus - CECT abdomen.</li><li>• X-ray findings indicate a mechanical obstruction</li><li>• step ladder pattern of air-fluid levels</li><li>• Option D: Adhesive obstruction – laparotomy . While adhesive obstruction may ultimately require surgical intervention , such as laparotomy , for definitive management , it is essential to first obtain imaging studies to confirm the diagnosis and evaluate the extent of the obstruction. A CECT abdomen provides valuable information about the underlying pathology , location of obstruction, and presence of complications such as bowel ischemia. Therefore, proceeding directly to laparotomy without prior imaging may not be warranted and could potentially lead to unnecessary surgery.</li><li>• Option D:</li><li>• Adhesive obstruction – laparotomy</li><li>• adhesive obstruction</li><li>• surgical intervention</li><li>• laparotomy</li><li>• definitive management</li><li>• CECT abdomen</li><li>• valuable information about the underlying pathology</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• While all options involve aspects of management for bowel obstruction , the presence of a step ladder pattern of air-fluid levels on X-ray suggests mechanical obstruction , likely due to adhesive obstruction . The next appropriate step is to obtain a CECT abdomen to further evaluate the etiology and extent of the obstruction before considering surgical intervention.</li><li>• involve aspects of management for bowel obstruction</li><li>• presence of a step ladder pattern of air-fluid levels on X-ray</li><li>• mechanical obstruction</li><li>• adhesive obstruction</li><li>• Causes of adhesions:</li><li>• Causes of adhesions:</li><li>• Acute inflammation: Sites of anastomosis, reperitonealization of raw areas, trauma, ischemia. Foreign material: Talc, starch, gauze, silk. Infection: Peritonitis, tuberculosis. Chronic inflammatory conditions: Crohn’s disease. Radiation enteritis</li><li>• Acute inflammation: Sites of anastomosis, reperitonealization of raw areas, trauma, ischemia.</li><li>• Acute inflammation: Sites of anastomosis, reperitonealization of raw areas, trauma, ischemia.</li><li>• Acute inflammation:</li><li>• Foreign material: Talc, starch, gauze, silk.</li><li>• Foreign material: Talc, starch, gauze, silk.</li><li>• Foreign material:</li><li>• Infection: Peritonitis, tuberculosis.</li><li>• Infection: Peritonitis, tuberculosis.</li><li>• Infection:</li><li>• Chronic inflammatory conditions: Crohn’s disease.</li><li>• Chronic inflammatory conditions: Crohn’s disease.</li><li>• Chronic inflammatory conditions:</li><li>• Radiation enteritis</li><li>• Radiation enteritis</li><li>• Management:</li><li>• Management:</li><li>• Initial management is based on intravenous rehydration and nasogastric decompression; occasionally, this treatment is curative. Although an initial conservative regimen is considered appropriate, regular assessment is mandatory to ensure that strangulation does not occur. Conservative treatment should not usually be prolonged beyond 72 hours. When laparotomy is required, although multiple adhesions may be found, only one may be causative. If there is absolute certainty that this is the cause of the obstruction, this should be divided and the remaining adhesions can be left in situ unless severe angulation is present.</li><li>• Initial management is based on intravenous rehydration and nasogastric decompression; occasionally, this treatment is curative. Although an initial conservative regimen is considered appropriate, regular assessment is mandatory to ensure that strangulation does not occur. Conservative treatment should not usually be prolonged beyond 72 hours.</li><li>• Initial management is based on intravenous rehydration and nasogastric decompression; occasionally, this treatment is curative. Although an initial conservative regimen is considered appropriate, regular assessment is mandatory to ensure that strangulation does not occur. Conservative treatment should not usually be prolonged beyond 72 hours.</li><li>• Initial management</li><li>• intravenous rehydration</li><li>• nasogastric decompression;</li><li>• When laparotomy is required, although multiple adhesions may be found, only one may be causative. If there is absolute certainty that this is the cause of the obstruction, this should be divided and the remaining adhesions can be left in situ unless severe angulation is present.</li><li>• When laparotomy is required, although multiple adhesions may be found, only one may be causative. If there is absolute certainty that this is the cause of the obstruction, this should be divided and the remaining adhesions can be left in situ unless severe angulation is present.</li><li>• Reference: Bailey and Love, 28 th Ed. Pg 1378, 1387.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of these are methods to prevent postoperative adhesions except:", "options": [{"label": "A", "text": "Laparoscopic surgery", "correct": false}, {"label": "B", "text": "Covering raw surfaces", "correct": false}, {"label": "C", "text": "Good contact with gauze for hemostasis", "correct": true}, {"label": "D", "text": "Minimal bowel handling", "correct": false}], "correct_answer": "C. Good contact with gauze for hemostasis", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Good contact with gauze for hemostasis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Laparoscopic surgery is associated with reduced postoperative adhesion formation compared to open surgery . The minimally invasive nature of laparoscopy involves smaller incisions and decreased tissue trauma, which can help reduce adhesion formation.</li><li>• Option A:</li><li>• Laparoscopic surgery</li><li>• reduced postoperative adhesion formation compared to open surgery</li><li>• Option B: Covering raw surfaces , such as anastomoses and raw peritoneal surfaces , can help prevent adhesion formation by providing a barrier between tissues and reducing tissue contact, thereby minimizing the risk of adhesion formation.</li><li>• Option B:</li><li>• Covering raw surfaces</li><li>• anastomoses and raw peritoneal surfaces</li><li>• prevent adhesion formation</li><li>• providing a barrier between tissues</li><li>• Option D: Minimizing bowel handling during surgery can help reduce tissue trauma and inflammation , thereby decreasing the risk of adhesion formation . Gentle tissue handling and avoiding excessive manipulation of the bowel can contribute to the prevention of postoperative adhesions.</li><li>• Option D:</li><li>• Minimizing bowel handling</li><li>• help reduce tissue trauma and inflammation</li><li>• decreasing the risk of adhesion formation</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Good contact with gauze for hemostasis is not recommended and may actually increase the risk of post-operative adhesion formation.</li><li>➤ Good contact with gauze for hemostasis</li><li>➤ not recommended</li><li>➤ actually increase the risk of post-operative adhesion formation.</li><li>➤ Factors that may limit adhesion formation include:</li><li>➤ Factors that may limit adhesion formation include:</li><li>➤ Good surgical technique Washing of the peritoneal cavity with saline to remove clots Minimizing contact with gauze Covering anastomoses and raw peritoneal surfaces</li><li>➤ Good surgical technique</li><li>➤ Washing of the peritoneal cavity with saline to remove clots</li><li>➤ Minimizing contact with gauze</li><li>➤ Covering anastomoses and raw peritoneal surfaces</li></ul>\n<p><strong>References:</strong></p><ul><li>↳ Reference:</li><li>↳ Bailey and Love, 28 th Ed. Pg 1378</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "While doing an emergency laparotomy for acute intestinal obstruction, which organ would you first visualize to check whether it is a small bowel or a large bowel obstruction?", "options": [{"label": "A", "text": "Ileum", "correct": false}, {"label": "B", "text": "Caecum", "correct": true}, {"label": "C", "text": "Rectum", "correct": false}, {"label": "D", "text": "Sigmoid colon", "correct": false}], "correct_answer": "B. Caecum", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Caecum</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• If the site of obstruction is unknown , adequate exposure is best achieved by a midline laparotomy incision .</li><li>• site of obstruction is unknown</li><li>• adequate exposure</li><li>• midline laparotomy incision</li><li>• Assessment is directed to:</li><li>• Assessment is directed to:</li><li>• The site of the obstruction If cecum is collapsed: it’s a small bowel obstruction If cecum is distended: large bowel The nature of the obstruction The viability of the gut If in doubt, the bowel should be wrapped in hot packs for 10 minutes and then reassessed. The state of the mesenteric vessels and pulsation in adjacent arcades should be sought. Viability is also confirmed by colour, sheen and peristalsis. If, at the end of this period, there is still uncertainty about bowel viability, it should be resected.</li><li>• The site of the obstruction If cecum is collapsed: it’s a small bowel obstruction If cecum is distended: large bowel</li><li>• The site of the obstruction</li><li>• If cecum is collapsed: it’s a small bowel obstruction If cecum is distended: large bowel</li><li>• If cecum is collapsed: it’s a small bowel obstruction</li><li>• If cecum is collapsed: it’s a small bowel obstruction</li><li>• If cecum is collapsed:</li><li>• If cecum is distended: large bowel</li><li>• If cecum is distended: large bowel</li><li>• If cecum is distended:</li><li>• The nature of the obstruction</li><li>• The nature of the obstruction</li><li>• The viability of the gut If in doubt, the bowel should be wrapped in hot packs for 10 minutes and then reassessed. The state of the mesenteric vessels and pulsation in adjacent arcades should be sought. Viability is also confirmed by colour, sheen and peristalsis. If, at the end of this period, there is still uncertainty about bowel viability, it should be resected.</li><li>• The viability of the gut</li><li>• If in doubt, the bowel should be wrapped in hot packs for 10 minutes and then reassessed. The state of the mesenteric vessels and pulsation in adjacent arcades should be sought. Viability is also confirmed by colour, sheen and peristalsis. If, at the end of this period, there is still uncertainty about bowel viability, it should be resected.</li><li>• If in doubt, the bowel should be wrapped in hot packs for 10 minutes and then reassessed. The state of the mesenteric vessels and pulsation in adjacent arcades should be sought. Viability is also confirmed by colour, sheen and peristalsis. If, at the end of this period, there is still uncertainty about bowel viability, it should be resected.</li><li>• If in doubt, the bowel should be wrapped in hot packs for 10 minutes and then reassessed. The state of the mesenteric vessels and pulsation in adjacent arcades should be sought. Viability is also confirmed by colour, sheen and peristalsis. If, at the end of this period, there is still uncertainty about bowel viability, it should be resected.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ While performing laparotomy for intestinal obstruction , visualising the cecum will help to differentiate small bowel (collapsed cecum) from colonic (distended cecum) obstruction.</li><li>➤ performing laparotomy for intestinal obstruction</li><li>➤ visualising the cecum</li><li>➤ differentiate small bowel</li><li>➤ from colonic</li><li>➤ obstruction.</li></ul>\n<p><strong>References:</strong></p><ul><li>↳ Reference: Bailey and Love, 28 th Ed. Pg 1386</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the incorrect statement with respect to caecal volvulus:", "options": [{"label": "A", "text": "More common in females", "correct": false}, {"label": "B", "text": "Barium study shows bird beak deformity", "correct": false}, {"label": "C", "text": "Volvulus is in clockwise direction", "correct": false}, {"label": "D", "text": "Recurrence rates are low with cecopexy", "correct": true}], "correct_answer": "D. Recurrence rates are low with cecopexy", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Recurrence rates are low with cecopexy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Caecal volvulus is indeed more common in females , particularly in the fourth and fifth decades of life. This demographic trend is noted in clinical presentations and epidemiological studies of the condition.</li><li>• Option A:</li><li>• Caecal volvulus is indeed more common in females</li><li>• Option B: A barium enema study can aid in the diagnosis of caecal volvulus by revealing characteristic findings such as the \"bird beak\" deformity, where the contrast column tapers abruptly at the site of the obstruction. This finding is consistent with the twisted segment of the colon seen in volvulus.</li><li>• Option B:</li><li>• barium enema study</li><li>• aid in the diagnosis of caecal volvulus</li><li>• revealing characteristic findings such as the \"bird beak\" deformity,</li><li>• contrast column tapers abruptly</li><li>• Option C: Caecal volvulus typically involves a clockwise twist , although variations in the direction of rotation can occur . This twisting of the bowel leads to obstruction and may result in ischemia if not promptly treated.</li><li>• Option C:</li><li>• Caecal volvulus typically involves a clockwise twist</li><li>• variations in the direction of rotation can occur</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Recurrence rates are high with cecopexy in a case of caecal voluvulus.</li><li>➤ Recurrence rates are high with cecopexy in a case of caecal voluvulus.</li><li>➤ Cecal volvulus may occur as part of volvulus neonatorum or de novo and is usually a clockwise twist . It is more common in females in the fourth and fifth decades and usually presents acutely with the classic features of obstruction. Ischaemia is common . In 25% of cases, examination may reveal a palpable tympanic swelling in the midline or left side of the abdomen. The volvulus typically results in the caecum lying in the left upper quadrant. Radiological abnormalities are identifiable in nearly all patients but are often non-specific, with caecal dilatation (98–100%), a single air–fluid level (72–88%), small bowel dilatation (42–55%) and absence of gas in distal colon (82–91%) reported as the most common abnormalities. A barium enema may be used to confirm the diagnosis if there are no concerns about ischaemia, with an absence of barium in the caecum and a bird’s beak deformity . CT scanning is now the imaging of choice . At operation the volvulus is frequently found to be ischaemic and needs resection. If viable, the volvulus should be reduced. Sometimes, this can only be achieved after decompression of the caecum using a needle. Further management consists of either resection or fixation of the caecum to the right iliac fossa (cecopexy) and/or a cecostomy in those considered unfit for resection. Recurrence of volvulus after cecopexy has been reported in up to 40% of cases.</li><li>➤ Cecal volvulus may occur as part of volvulus neonatorum or de novo and is usually a clockwise twist . It is more common in females in the fourth and fifth decades and usually presents acutely with the classic features of obstruction. Ischaemia is common .</li><li>➤ Cecal volvulus</li><li>➤ part of volvulus neonatorum or de novo</li><li>➤ usually a clockwise twist</li><li>➤ Ischaemia is common</li><li>➤ In 25% of cases, examination may reveal a palpable tympanic swelling in the midline or left side of the abdomen. The volvulus typically results in the caecum lying in the left upper quadrant.</li><li>➤ Radiological abnormalities are identifiable in nearly all patients but are often non-specific, with caecal dilatation (98–100%), a single air–fluid level (72–88%), small bowel dilatation (42–55%) and absence of gas in distal colon (82–91%) reported as the most common abnormalities.</li><li>➤ Radiological abnormalities</li><li>➤ nearly all patients but are often non-specific, with caecal dilatation</li><li>➤ A barium enema may be used to confirm the diagnosis if there are no concerns about ischaemia, with an absence of barium in the caecum and a bird’s beak deformity . CT scanning is now the imaging of choice .</li><li>➤ barium enema</li><li>➤ used to confirm the diagnosis</li><li>➤ bird’s beak deformity</li><li>➤ imaging of choice</li><li>➤ At operation the volvulus is frequently found to be ischaemic and needs resection. If viable, the volvulus should be reduced. Sometimes, this can only be achieved after decompression of the caecum using a needle. Further management consists of either resection or fixation of the caecum to the right iliac fossa (cecopexy) and/or a cecostomy in those considered unfit for resection.</li><li>➤ Recurrence of volvulus after cecopexy has been reported in up to 40% of cases.</li><li>➤ Recurrence of volvulus after cecopexy has been reported in up to 40% of cases.</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 1383, 1390</li><li>➤ Ref:</li><li>➤ Bailey and Love, 28 th Ed. Pg 1383, 1390</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of these are treatment options for sigmoid volvulus except?", "options": [{"label": "A", "text": "High-pressure enema", "correct": true}, {"label": "B", "text": "Passage of flatus tube", "correct": false}, {"label": "C", "text": "Sigmoid colectomy", "correct": false}, {"label": "D", "text": "Hartmann’s procedure", "correct": false}], "correct_answer": "A. High-pressure enema", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) High-pressure enema</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Passage of a flatus tube , typically performed under endoscopic or fluoroscopic guidance , is a common initial intervention for sigmoid volvulus . The tube helps to decompress the distended sigmoid colon , relieving the obstruction and reducing the risk of ischemia. Securing the flatus tube in place allows for continuous decompression until the volvulus resolves.</li><li>• Option B:</li><li>• Passage of a flatus tube</li><li>• performed under endoscopic or fluoroscopic guidance</li><li>• initial intervention for sigmoid volvulus</li><li>• tube helps to decompress the distended sigmoid colon</li><li>• Option C: Sigmoid colectomy , involving the surgical resection of the sigmoid colon , is often necessary for definitive treatment of recurrent or complicated sigmoid volvulus . This procedure removes the segment of the colon prone to volvulus formation, reducing the risk of recurrence and associated complications.</li><li>• Option C:</li><li>• Sigmoid colectomy</li><li>• surgical resection of the sigmoid colon</li><li>• definitive treatment of recurrent or complicated sigmoid volvulus</li><li>• Option D: Hartmann’s procedure involves the resection of the diseased segment of the colon (in this case, the sigmoid colon affected by volvulus) with closure of the rectal stump and formation of an end colostomy.</li><li>• Option D:</li><li>• Hartmann’s procedure</li><li>• resection of the diseased segment</li><li>• colon</li><li>• closure of the rectal stump</li><li>• formation of an end colostomy.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ High pressure enema , is not recommended due to the potential for exacerbating the condition . Flatus tube insertion , sigmoid colectomy , and Hartmann’s procedure are preferred management strategies depending on the clinical scenario and severity of the volvulus.</li><li>➤ High pressure enema</li><li>➤ not recommended due to the potential for exacerbating the condition</li><li>➤ Flatus tube insertion</li><li>➤ sigmoid colectomy</li><li>➤ Hartmann’s procedure</li><li>➤ management strategies</li><li>➤ severity of the volvulus.</li><li>➤ Rx:</li><li>➤ Rx:</li><li>➤ Flexible sigmoidoscopy or rigid sigmoidoscopy and insertion of a flatus tube should be carried out to allow deflation of the gut. The tube should be secured in place with tape for 24 hours and a repeat radiograph taken to ensure that decompression has occurred. Success, as long as ischaemic bowel is excluded, will resolve the acute problem. In fit patients, an elective sigmoid colectomy is required. It may not be reasonable to offer any further treatment following successful endoscopic decompression in elderly or unfit patients; however, if there are recurrent episodes of volvulus, the options are resection or two-point fixation with combined endoscopic/percutaneous tube insertion (gastrostomy tubes are frequently used for this purpose). When the bowel is viable, fixation of the sigmoid colon to the posterior abdominal wall may be a safer maneuver in inexperienced hands. Resection is preferable if it can be achieved safely. A Paul–Mikulicz procedure is useful, particularly if there is suspicion of impending gangrene an alternative procedure is a sigmoid colectomy and, when anastomosis is considered unwise, a Hartmann’s procedure with subsequent re-anastomosis can be carried out.</li><li>➤ Flexible sigmoidoscopy or rigid sigmoidoscopy and insertion of a flatus tube should be carried out to allow deflation of the gut. The tube should be secured in place with tape for 24 hours and a repeat radiograph taken to ensure that decompression has occurred. Success, as long as ischaemic bowel is excluded, will resolve the acute problem.</li><li>➤ Flexible sigmoidoscopy or rigid sigmoidoscopy</li><li>➤ In fit patients, an elective sigmoid colectomy is required. It may not be reasonable to offer any further treatment following successful endoscopic decompression in elderly or unfit patients; however, if there are recurrent episodes of volvulus, the options are resection or two-point fixation with combined endoscopic/percutaneous tube insertion (gastrostomy tubes are frequently used for this purpose).</li><li>➤ When the bowel is viable, fixation of the sigmoid colon to the posterior abdominal wall may be a safer maneuver in inexperienced hands. Resection is preferable if it can be achieved safely.</li><li>➤ A Paul–Mikulicz procedure is useful, particularly if there is suspicion of impending gangrene an alternative procedure is a sigmoid colectomy and, when anastomosis is considered unwise, a Hartmann’s procedure with subsequent re-anastomosis can be carried out.</li><li>➤ Paul–Mikulicz procedure</li><li>➤ Ref: Bailey and Love, 28 th Ed. Page 1390</li><li>➤ Ref:</li><li>➤ Bailey and Love, 28 th Ed. Page 1390</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Absolute constipation (obstipation) is not a necessary feature in which of these causes of acute intestinal obstruction?", "options": [{"label": "A", "text": "Sigmoid volvulus", "correct": false}, {"label": "B", "text": "Obstructed hernia", "correct": false}, {"label": "C", "text": "Complete ileal stricture", "correct": false}, {"label": "D", "text": "Richter’s hernia", "correct": true}], "correct_answer": "D. Richter’s hernia", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Richter’s hernia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Constipation may be classified as absolute (i.e. neither feces nor flatus is passed) or relative (where only flatus is passed). Absolute constipation is a cardinal feature of complete intestinal obstruction. Some patients may pass flatus or feces after the onset of obstruction as a result of the evacuation of the distal bowel contents. It a not a feature of Richter’s hernia</li><li>• Constipation may be classified as absolute (i.e. neither feces nor flatus is passed) or relative (where only flatus is passed).</li><li>• Constipation</li><li>• classified as absolute</li><li>• relative</li><li>• Absolute constipation is a cardinal feature of complete intestinal obstruction. Some patients may pass flatus or feces after the onset of obstruction as a result of the evacuation of the distal bowel contents.</li><li>• Absolute constipation is a cardinal feature of complete intestinal obstruction.</li><li>• It a not a feature of Richter’s hernia</li><li>• It a not a feature of Richter’s hernia</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The rule that absolute constipation is present in intestinal obstruction does not apply in:</li><li>➤ The rule that absolute constipation is present in intestinal obstruction does not apply in:</li><li>➤ Richter’s hernia; Gallstone ileus; Mesenteric vascular occlusion; Functional obstruction associated with pelvic abscess; All cases of partial obstruction (in which diarrhea may occur).</li><li>➤ Richter’s hernia;</li><li>➤ Gallstone ileus;</li><li>➤ Mesenteric vascular occlusion;</li><li>➤ Functional obstruction associated with pelvic abscess;</li><li>➤ All cases of partial obstruction (in which diarrhea may occur).</li><li>➤ Ref. Bailey and Love 28 th Ed. Pg 1381-82.</li><li>➤ Ref.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of the below form the anterior relations of the rectum except?", "options": [{"label": "A", "text": "Pouch of Douglas", "correct": false}, {"label": "B", "text": "Fascia of Denonvilliers", "correct": false}, {"label": "C", "text": "Urinary Bladder", "correct": false}, {"label": "D", "text": "Waldeyer’s fascia", "correct": true}], "correct_answer": "D. Waldeyer’s fascia", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/screenshot-2024-03-29-155657.png"], "explanation": "<p><strong>Ans. D) Waldeyer’s fascia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Pouch of Douglas is the extension of the peritoneal cavity between the rectum and the uterus in females , and it is indeed an anterior relation of the rectum.</li><li>• Option A: Pouch of Douglas</li><li>• extension of the peritoneal cavity</li><li>• rectum and the uterus in females</li><li>• Option B: Fascia of Denonvilliers is a fascial layer between the rectum and the prostate or vagina and is an anterior relation of the rectum.</li><li>• Option B: Fascia of Denonvilliers</li><li>• fascial layer</li><li>• rectum and the prostate or vagina</li><li>• Option C: Bladder in males , the base of the bladder is separated from the rectum by the fascia of Denonvilliers and is an anterior relation.</li><li>• Option C: Bladder</li><li>• males</li><li>• base of the bladder is separated from the rectum</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Waldeyer’s fascia forms the posterior relation of the rectum and is not an anterior relation, making D the correct answer.</li><li>➤ Waldeyer’s fascia</li><li>➤ posterior relation of the rectum</li><li>➤ not an anterior relation,</li><li>➤ The other anatomical relations of the rectum include:</li><li>➤ The other anatomical relations of the rectum include:</li><li>➤ Ref : Bailey and Love 28th ed. Pg 1393</li><li>➤ Ref</li><li>➤ : Bailey and Love 28th ed. Pg 1393</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 55-year-old male with a history of a malignant pelvic tumor presents with inguinal lymphadenopathy. Which of the following primary tumor locations is least likely to account for this presentation?", "options": [{"label": "A", "text": "Anus", "correct": false}, {"label": "B", "text": "Penis", "correct": false}, {"label": "C", "text": "Rectum", "correct": true}, {"label": "D", "text": "Squamous cell carcinoma of the thigh", "correct": false}], "correct_answer": "C. Rectum", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Rectum</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Anus malignancies typically drain into the superficial inguinal lymph nodes , so inguinal lymphadenopathy is common with anal cancer.</li><li>• Option A: Anus</li><li>• malignancies</li><li>• drain into the superficial inguinal lymph nodes</li><li>• Option B: Penis malignancies often metastasize to the inguinal lymph nodes due to the drainage patterns of the superficial lymphatic vessels of the penile area.</li><li>• Option B: Penis</li><li>• malignancies</li><li>• metastasize to the inguinal lymph nodes</li><li>• Option D: Squamous cell carcinomas of the thigh commonly spread to the superficial inguinal lymph nodes , as they are the primary drainage sites for the thigh area.</li><li>• Option D: Squamous cell carcinomas of the thigh</li><li>• spread to the superficial inguinal lymph nodes</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Rectal malignancies typically do not spread to inguinal lymph nodes as their primary lymphatic drainage is upward towards the mesenteric nodes .</li><li>➤ Rectal malignancies</li><li>➤ do not spread to inguinal lymph nodes</li><li>➤ primary lymphatic drainage</li><li>➤ upward towards the mesenteric nodes</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1394</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1394</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient with tenesmus and fresh bleeding PR, came to the OPD. The surgeon wants to visualize the rectum and anal canal using a proctoscope. The normal length visualized by proctoscopy is?", "options": [{"label": "A", "text": "5 cm", "correct": false}, {"label": "B", "text": "10 cm", "correct": true}, {"label": "C", "text": "20 cm", "correct": false}, {"label": "D", "text": "30 cm", "correct": false}], "correct_answer": "B. 10 cm", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) 10 cm</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Proctoscope can be used to inspect the anus , anorectal junction and lower rectum , 10-15 cm . Proctoscopy can be used to inspect the anus, anorectal junction and lower rectum. A lubricated proctoscope is inserted through the anus to provide views of the lower rectum and anal canal . Biopsy can be performed of any suspicious areas, provided it is above the sensitive anoderm. Proctoscopy is particularly useful for assessing the presence of haemorrhoids. Sigmoidoscopy in the past, was a rigid stainless-steel instrument of variable diameter and normally 25 cm in length , but this has been replaced by disposable plastic instruments. The rectum must be empty for proper inspection. Direct inspection of the rectal mucosa may alert the clinician to inflammation or tumours. This procedure can be performed in the outpatient setting . Flexible sigmoidoscope: This is used as a supplement to rigid sigmoidoscopy or when views proximal to the rectum are required. It has a usable length of 60 cm. The lower bowel needs to be cleaned out with preliminary enemas. In addition to the rectum, the whole sigmoid colon up to the splenic flexure is within visual reach.</li><li>• Proctoscope can be used to inspect the anus , anorectal junction and lower rectum , 10-15 cm . Proctoscopy can be used to inspect the anus, anorectal junction and lower rectum.</li><li>• Proctoscope</li><li>• used to inspect the anus</li><li>• anorectal junction</li><li>• lower rectum</li><li>• 10-15 cm</li><li>• Proctoscopy can be used to inspect the anus, anorectal junction and lower rectum.</li><li>• A lubricated proctoscope is inserted through the anus to provide views of the lower rectum and anal canal . Biopsy can be performed of any suspicious areas, provided it is above the sensitive anoderm. Proctoscopy is particularly useful for assessing the presence of haemorrhoids.</li><li>• lubricated proctoscope</li><li>• anus to provide views of the lower rectum and anal canal</li><li>• Sigmoidoscopy in the past, was a rigid stainless-steel instrument of variable diameter and normally 25 cm in length , but this has been replaced by disposable plastic instruments. The rectum must be empty for proper inspection. Direct inspection of the rectal mucosa may alert the clinician to inflammation or tumours. This procedure can be performed in the outpatient setting .</li><li>• Sigmoidoscopy</li><li>• rigid</li><li>• stainless-steel instrument</li><li>• 25 cm in length</li><li>• outpatient setting</li><li>• Flexible sigmoidoscope: This is used as a supplement to rigid sigmoidoscopy or when views proximal to the rectum are required. It has a usable length of 60 cm. The lower bowel needs to be cleaned out with preliminary enemas. In addition to the rectum, the whole sigmoid colon up to the splenic flexure is within visual reach.</li><li>• Flexible sigmoidoscope:</li><li>• views proximal to the rectum</li><li>• It has a usable length of 60 cm.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The proctoscope is commonly used to inspect the anus , anorectal junction , and lower rectum up to 10-15 cm .</li><li>➤ proctoscope</li><li>➤ commonly used to inspect the anus</li><li>➤ anorectal junction</li><li>➤ lower rectum up to 10-15 cm</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1395.</li><li>➤ Ref :</li><li>➤ Bailey and Love, 28 th Ed. Pg 1395.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 35-year-old postpartum female, presented to the OPD with something coming out per anus. The following image was obtained on examination. What is incorrect about the following condition?", "options": [{"label": "A", "text": "Mucosal prolapse is more common in children compared to adults", "correct": false}, {"label": "B", "text": "Delorme’s procedure is through the perineal approach", "correct": false}, {"label": "C", "text": "Digital repositioning can be tried in adults for full thickness prolapse", "correct": true}, {"label": "D", "text": "Solitary rectal ulcer syndrome may be a complication of obstructed defecation syndrome", "correct": false}], "correct_answer": "C. Digital repositioning can be tried in adults for full thickness prolapse", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1.png"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Digital repositioning can be tried in adults for full thickness prolapse</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Suggests that mucosal prolapse is more common in children than in adults . Mucosal prolapse refers to the prolapse of only the mucosal layer of the rectum and is indeed more commonly seen in children.</li><li>• Option A:</li><li>• mucosal prolapse is more common in children than in adults</li><li>• Option B: States that Delorme’s procedure is performed through the perineal approach . This is correct; Delorme’s procedure is a perineal approach for rectal prolapse that involves resection of redundant rectal mucosa.</li><li>• Option B:</li><li>• Delorme’s procedure is performed through the perineal approach</li><li>• Option D: Mentions that Solitary rectal ulcer syndrome may be a complication of obstructed defecation syndrome. This is true as the repetitive trauma from straining can lead to ulceration in the rectum.</li><li>• Option D:</li><li>• Solitary rectal ulcer syndrome may be a complication of obstructed defecation syndrome.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The incorrect statement is C, as digital repositioning is generally not recommended for adults with rectal prolapse ; more definitive surgical management is often required.</li><li>➤ incorrect statement</li><li>➤ digital repositioning</li><li>➤ not recommended for adults with rectal prolapse</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg1398</li><li>➤ Ref :</li><li>➤ Bailey and Love, 28 th Ed. Pg1398</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the incorrect statement concerning a full-thickness rectal prolapse:", "options": [{"label": "A", "text": "Anorexia nervosa is a risk factor", "correct": false}, {"label": "B", "text": "Associated with malnutrition in children", "correct": false}, {"label": "C", "text": "Altemeier operation has lower recurrence rates than Delorme", "correct": false}, {"label": "D", "text": "Men are affected 6 times more than females", "correct": true}], "correct_answer": "D. Men are affected 6 times more than females", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Men are affected 6 times more than females</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Rectal prolapse is associated with anorexia nervosa . While it's more common in the elderly and can occur with conditions that cause chronic straining or weaken the pelvic floor , an association with anorexia nervosa is possible due to malnutrition effects on muscles and connective tissue.</li><li>• Option A:</li><li>• Rectal prolapse</li><li>• associated with anorexia nervosa</li><li>• more common in the elderly</li><li>• cause chronic straining</li><li>• weaken the pelvic floor</li><li>• Option B : Suggests an association with malnutrition in children . Malnutrition can lead to weakened support structures and muscles , potentially contributing to prolapse in pediatric populations.</li><li>• Option B</li><li>• malnutrition in children</li><li>• Malnutrition</li><li>• weakened support structures and muscles</li><li>• Option C: States that the Altemeier operation has low recurrence rates . Recurrence rates for the Altemeier procedure can vary from 0 to 20%, which are lower than perineal procedures.</li><li>• Option C:</li><li>• Altemeier operation has low recurrence rates</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Full-thickness rectal prolapse is more commonly seen in women , who are affected six times more often than men.</li><li>➤ Full-thickness rectal prolapse</li><li>➤ commonly seen in women</li><li>➤ affected six times more often than men.</li><li>➤ The protrusion consists of all layers of the rectal wall and is usually associated with a weak pelvic floor and/or chronic straining. Complete prolapse is uncommon in children but may occur as a result of malnutrition. In adults, it can occur at any age, but it is more common in the elderly and sometimes in patients with anorexia nervosa . Women are affected six times more often than men. Recurrence rates range from 0% to 20% in the Altemeier procedure. This is the procedure of choice in patients presenting with incarcerated and strangulated prolapse. It is a good alternative perineal procedure to the Delorme’s operation, particularly following recurrence.</li><li>➤ The protrusion consists of all layers of the rectal wall and is usually associated with a weak pelvic floor and/or chronic straining.</li><li>➤ Complete prolapse is uncommon in children but may occur as a result of malnutrition. In adults, it can occur at any age, but it is more common in the elderly and sometimes in patients with anorexia nervosa .</li><li>➤ more common in the elderly and sometimes in patients with anorexia nervosa</li><li>➤ Women are affected six times more often than men.</li><li>➤ Recurrence rates range from 0% to 20% in the Altemeier procedure. This is the procedure of choice in patients presenting with incarcerated and strangulated prolapse. It is a good alternative perineal procedure to the Delorme’s operation, particularly following recurrence.</li><li>➤ Ref : Bailey and Love 28 th Ed., Pg. 1399-1400</li><li>➤ Ref :</li><li>➤ Bailey and Love 28 th Ed., Pg. 1399-1400</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these procedures for rectal prolapse is not via perineal approach?", "options": [{"label": "A", "text": "Thiersch’s operation", "correct": false}, {"label": "B", "text": "Mesh rectopexy", "correct": true}, {"label": "C", "text": "Delorme’s operation", "correct": false}, {"label": "D", "text": "Altemeier procedure", "correct": false}], "correct_answer": "B. Mesh rectopexy", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Mesh rectopexy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Thiersch’s operation . In this perineal approach procedure , a steel wire , or silastic or nylon tape , is placed around the anal canal . It has become largely obsolete owing to problems with chronic perineal sepsis , anal stenosis and obstructed defecation, but may be used to augment perineal repair in cases of severe pelvic floor weakness.</li><li>• Option A: Thiersch’s operation</li><li>• perineal approach</li><li>• procedure</li><li>• steel wire</li><li>• silastic or nylon tape</li><li>• placed around the anal canal</li><li>• become largely obsolete owing to problems with chronic perineal sepsis</li><li>• Option C: In Delorme procedure , the rectal mucosa is stripped circumferentially from the rectum over the length of the prolapse . The underlying muscle is plicated with a series of sutures, so that the rectal muscle is concave towards the anal canal. The excess rectal mucosa is excised and a mucosal anastomosis performed.</li><li>• Option C:</li><li>• Delorme</li><li>• procedure</li><li>• rectal mucosa is stripped</li><li>• circumferentially</li><li>• rectum over the length of the prolapse</li><li>• Option D: In the Altemeier procedure, the rectum is prolapsed through the anal canal and a full thickness resection performed , incorporating any associated colonic prolapse. Restoration of colorectal continuity can be performed by either a handsewn or stapled anastomosis . This is the procedure of choice in patients presenting with incarcerated and strangulated prolapse.</li><li>• Option D:</li><li>• full thickness resection performed</li><li>• . This is the procedure of choice in patients presenting with incarcerated and strangulated prolapse.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The procedure for rectal prolapse not performed via the perineal approach is mesh rectopexy , an abdominal operation that aims to fix the rectum in its normal anatomical position .</li><li>➤ procedure for rectal prolapse</li><li>➤ not performed</li><li>➤ perineal approach is mesh rectopexy</li><li>➤ abdominal operation</li><li>➤ aims to fix the rectum in its normal anatomical position</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg. 1399-1400</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg. 1399-1400</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of the below increase the risk for colorectal cancer except?", "options": [{"label": "A", "text": "Lynch syndrome", "correct": false}, {"label": "B", "text": "Ulcerative colitis", "correct": false}, {"label": "C", "text": "Juvenile polyp", "correct": true}, {"label": "D", "text": "Smoking", "correct": false}], "correct_answer": "C. Juvenile polyp", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Juvenile polyp</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• It is the 2nd most common cancer in females and the 3rd most common cancer in males . Other risk factors include diet, smoking (Option D), obesity and alcohol consumption. People with inflammatory bowel disease (UC) are at an increased risk. (option B) Number of genetic syndromes are also associated with higher rates of colorectal cancer. The most common is hereditary nonpolyposis colorectal cancer (HNPCC or Lynch syndrome), which accounts for 3% of people with colorectal cancer (Option A). Other syndromes include Gardner syndrome and FAP . Juvenile polyp: This is a bright red, glistening pedunculated sphere (‘cherry tumour’) that is found in infants and children that may persist into adult life. It can cause bleeding or pain if it prolapses during defecation. It often separates spontaneously but can be removed easily with forceps or a snare. A solitary juvenile polyp has virtually no tendency to malignant change but should be treated if symptomatic.</li><li>• It is the 2nd most common cancer in females and the 3rd most common cancer in males . Other risk factors include diet, smoking (Option D), obesity and alcohol consumption.</li><li>• It is the 2nd most common cancer in females and the 3rd most common cancer in males . Other risk factors include diet, smoking (Option D), obesity and alcohol consumption.</li><li>• 2nd most common cancer in females and the 3rd most common cancer in males</li><li>• People with inflammatory bowel disease (UC) are at an increased risk. (option B)</li><li>• People with inflammatory bowel disease (UC) are at an increased risk. (option B)</li><li>• inflammatory bowel disease (UC)</li><li>• Number of genetic syndromes are also associated with higher rates of colorectal cancer. The most common is hereditary nonpolyposis colorectal cancer (HNPCC or Lynch syndrome), which accounts for 3% of people with colorectal cancer (Option A). Other syndromes include Gardner syndrome and FAP .</li><li>• Number of genetic syndromes are also associated with higher rates of colorectal cancer. The most common is hereditary nonpolyposis colorectal cancer (HNPCC or Lynch syndrome), which accounts for 3% of people with colorectal cancer (Option A). Other syndromes include Gardner syndrome and FAP .</li><li>• most common is hereditary nonpolyposis colorectal cancer</li><li>• Gardner syndrome and FAP</li><li>• Juvenile polyp: This is a bright red, glistening pedunculated sphere (‘cherry tumour’) that is found in infants and children that may persist into adult life. It can cause bleeding or pain if it prolapses during defecation. It often separates spontaneously but can be removed easily with forceps or a snare. A solitary juvenile polyp has virtually no tendency to malignant change but should be treated if symptomatic.</li><li>• Juvenile polyp: This is a bright red, glistening pedunculated sphere (‘cherry tumour’) that is found in infants and children that may persist into adult life. It can cause bleeding or pain if it prolapses during defecation. It often separates spontaneously but can be removed easily with forceps or a snare. A solitary juvenile polyp has virtually no tendency to malignant change but should be treated if symptomatic.</li><li>• Juvenile polyp:</li><li>• (‘cherry tumour’)</li><li>• A solitary juvenile polyp has virtually no tendency to malignant change but should be treated if symptomatic.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Solitary juvenile polyps are not commonly associated with an increased risk of colorectal cancer and typically have no malignant potential.</li><li>➤ Solitary juvenile polyps</li><li>➤ not commonly associated with an increased risk of colorectal cancer</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1403-1405</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1403-1405</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old patient presents with a six-month history of rectal symptoms. Which symptom is most likely to represent the earliest manifestation of rectal cancer?", "options": [{"label": "A", "text": "Tenesmus", "correct": false}, {"label": "B", "text": "Early morning diarrhea", "correct": false}, {"label": "C", "text": "Pelvic pain", "correct": false}, {"label": "D", "text": "Bleeding PR", "correct": true}], "correct_answer": "D. Bleeding PR", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Bleeding PR</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Tenesmus is the sensation of incomplete emptying after a bowel movement , which can occur in rectal cancer but is not typically the earliest symptom.</li><li>• Option A: Tenesmus</li><li>• sensation of incomplete emptying after a bowel movement</li><li>• Option B: Early morning diarrhea may be associated with a change in bowel habits seen in colorectal cancer , but it is not the most common initial symptom.</li><li>• Option B: Early morning diarrhea</li><li>• change in bowel habits seen in colorectal cancer</li><li>• Option C: Pain in pelvis is usually a later symptom in the course of rectal cancer , occurring as the disease progresses and invades surrounding tissues.</li><li>• Option C: Pain in pelvis</li><li>• later symptom in the course of rectal cancer</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The earliest and most common symptom of rectal cancer is often painless bleeding PR , typically presenting as bright red blood . Pain is typically a later symptom as the disease progresses.</li><li>➤ earliest and most common symptom of rectal cancer is often painless bleeding PR</li><li>➤ bright red blood</li><li>➤ Ref : Bailey and Love 28 th Ed., Pg. 1406</li><li>➤ Ref : Bailey and Love 28 th Ed., Pg. 1406</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 65-year-old male came to the OPD with complaints of bleeding PR with tenesmus. On the PR examination, a mass was felt. A diagnosis of rectal cancer was made. Which investigation modality will be used for local staging in such a patient?", "options": [{"label": "A", "text": "Flexible sigmoidoscopy", "correct": false}, {"label": "B", "text": "CECT Abdomen", "correct": false}, {"label": "C", "text": "Colonoscopy", "correct": false}, {"label": "D", "text": "MRI pelvis", "correct": true}], "correct_answer": "D. MRI pelvis", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) MRI pelvis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Flexible sigmoidoscopy is often used for initial diagnosis and can help visualize the rectum and the lower part of the colon , but it does not provide detailed information on local invasion or staging.</li><li>• Option A: Flexible sigmoidoscopy</li><li>• initial diagnosis</li><li>• can help visualize the rectum and the lower part of the colon</li><li>• Option B: Contrast-Enhanced CT [CECT] Abdomen can be used to evaluate the abdomen and pelvis for metastatic disease but is less precise than MRI for assessing the local extent of rectal tumors.</li><li>• Option B: Contrast-Enhanced CT [CECT] Abdomen</li><li>• evaluate the abdomen and pelvis for metastatic disease</li><li>• Option C: Colonoscopy is essential for full colorectal visualization and is necessary to exclude synchronous tumors ; however, it is not the best modality for local staging.</li><li>• Option C: Colonoscopy</li><li>• full colorectal visualization</li><li>• exclude synchronous tumors</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ For local staging of rectal cancer , MRI of the pelvis is the preferred modality due to its superior soft tissue resolution , which aids in detailed assessment of the tumor's local spread and mesorectal involvement.</li><li>➤ local staging of rectal cancer</li><li>➤ MRI of the pelvis</li><li>➤ preferred modality due to its superior soft tissue resolution</li><li>➤ tumor's local spread and mesorectal involvement.</li><li>➤ All patients with suspected rectal cancer should undergo:</li><li>➤ All patients with suspected rectal cancer should undergo:</li><li>➤ Digital rectal examination Full colorectal visualization, preferably by colonoscopy with biopsy or CT colonography, or barium enema All patients with proven rectal cancer require staging by: Imaging of the chest, abdomen and pelvis, preferably by CT Local pelvic imaging by magnetic resonance imaging (MRI) and/or endoluminal ultrasonography</li><li>➤ Digital rectal examination</li><li>➤ Digital rectal examination</li><li>➤ Full colorectal visualization, preferably by colonoscopy with biopsy or CT colonography, or barium enema</li><li>➤ Full colorectal visualization, preferably by colonoscopy with biopsy or CT colonography, or barium enema</li><li>➤ All patients with proven rectal cancer require staging by: Imaging of the chest, abdomen and pelvis, preferably by CT Local pelvic imaging by magnetic resonance imaging (MRI) and/or endoluminal ultrasonography</li><li>➤ All patients with proven rectal cancer require staging by:</li><li>➤ All patients with proven rectal cancer require staging by:</li><li>➤ Imaging of the chest, abdomen and pelvis, preferably by CT Local pelvic imaging by magnetic resonance imaging (MRI) and/or endoluminal ultrasonography</li><li>➤ Imaging of the chest, abdomen and pelvis, preferably by CT</li><li>➤ Imaging of the chest, abdomen and pelvis, preferably by CT</li><li>➤ Local pelvic imaging by magnetic resonance imaging (MRI) and/or endoluminal ultrasonography</li><li>➤ Local pelvic imaging by magnetic resonance imaging (MRI) and/or endoluminal ultrasonography</li><li>➤ magnetic resonance imaging (MRI)</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1406-07</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1406-07</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 55-year-old female was diagnosed with rectal cancer on colonoscopy after tissue biopsy. The growth extends to the extra-rectal tissues but without metastasis to the regional lymph nodes. What is the Duke's likely staging?", "options": [{"label": "A", "text": "A", "correct": false}, {"label": "B", "text": "B", "correct": true}, {"label": "C", "text": "C", "correct": false}, {"label": "D", "text": "D", "correct": false}], "correct_answer": "B. B", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) B</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Dukes staging:</li><li>• Dukes staging:</li><li>• Stage A: The growth is limited to the rectal wall (15%). The prognosis is excellent (&gt;90% 5year survival). Stage B: The growth extends to the extra rectal tissues, but without metastasis to the regional lymph nodes (35%). The prognosis is reasonable (70% 5year survival). Stage C: There are secondary deposits in the regional lymph nodes (50%). These are subdivided into C1, in which the local para-rectal lymph nodes alone are involved, and C2, in which the nodes accompanying the supplying blood vessels to their origin from the aorta are involved. This does not take into account cases that have metastasis beyond the regional lymph nodes or by way of the venous system. The prognosis is poor (40% 5year survival). Stage D is often included, which was not described by Dukes. This stage signifies the presence of widespread metastases, usually hepatic. Other staging systems have been developed (e.g., Astler-Coller, TNM) to improve prognostic accuracy,</li><li>• Stage A: The growth is limited to the rectal wall (15%). The prognosis is excellent (&gt;90% 5year survival).</li><li>• Stage A: The growth is limited to the rectal wall (15%). The prognosis is excellent (&gt;90% 5year survival).</li><li>• Stage A:</li><li>• limited to the rectal wall</li><li>• Stage B: The growth extends to the extra rectal tissues, but without metastasis to the regional lymph nodes (35%). The prognosis is reasonable (70% 5year survival).</li><li>• Stage B: The growth extends to the extra rectal tissues, but without metastasis to the regional lymph nodes (35%). The prognosis is reasonable (70% 5year survival).</li><li>• Stage B:</li><li>• extra rectal tissues, but without metastasis</li><li>• Stage C: There are secondary deposits in the regional lymph nodes (50%). These are subdivided into C1, in which the local para-rectal lymph nodes alone are involved, and C2, in which the nodes accompanying the supplying blood vessels to their origin from the aorta are involved. This does not take into account cases that have metastasis beyond the regional lymph nodes or by way of the venous system. The prognosis is poor (40% 5year survival).</li><li>• Stage C: There are secondary deposits in the regional lymph nodes (50%). These are subdivided into C1, in which the local para-rectal lymph nodes alone are involved, and C2, in which the nodes accompanying the supplying blood vessels to their origin from the aorta are involved. This does not take into account cases that have metastasis beyond the regional lymph nodes or by way of the venous system. The prognosis is poor (40% 5year survival).</li><li>• Stage C:</li><li>• secondary deposits</li><li>• in the regional lymph nodes</li><li>• Stage D is often included, which was not described by Dukes. This stage signifies the presence of widespread metastases, usually hepatic. Other staging systems have been developed (e.g., Astler-Coller, TNM) to improve prognostic accuracy,</li><li>• Stage D is often included, which was not described by Dukes. This stage signifies the presence of widespread metastases, usually hepatic. Other staging systems have been developed (e.g., Astler-Coller, TNM) to improve prognostic accuracy,</li><li>• Stage D</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Duke's Stage B is characterized by the extension of the tumor to the extra-rectal tissues without regional lymph node involvement , which correlates with a reasonable prognosis of approximately 70% 5-year survival.</li><li>➤ Duke's Stage B</li><li>➤ extension of the tumor to the extra-rectal tissues</li><li>➤ regional lymph node involvement</li><li>➤ correlates with a reasonable prognosis of approximately 70% 5-year survival.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg.1407</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg.1407</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A tumor penetrating the mesorectum is classified as what stage in the TNM staging of rectal cancer?", "options": [{"label": "A", "text": "T2", "correct": false}, {"label": "B", "text": "T3", "correct": true}, {"label": "C", "text": "T4A", "correct": false}, {"label": "D", "text": "T4B", "correct": false}], "correct_answer": "B. T3", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/screenshot-2024-03-29-163826.png"], "explanation": "<p><strong>Ans. B)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: T2 describes a tumor that invades the muscularis propria but does not extend into the mesorectum.</li><li>• Option A: T2</li><li>• tumor that invades the muscularis propria</li><li>• Option C: T4A refers to a tumor that has penetrated through the peritoneum , representing a more advanced local disease than T3.</li><li>• Option C: T4A</li><li>• tumor that has penetrated through the peritoneum</li><li>• Option D: T4B is used for a tumor that has invaded adjacent organs or structures.</li><li>• Option D: T4B</li><li>• tumor that has invaded adjacent organs or structures.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ A rectal cancer tumor that has penetrated into the mesorectum is classified as T3 in the TNM staging system.</li><li>➤ rectal cancer tumor</li><li>➤ penetrated into the mesorectum</li><li>➤ T3 in the TNM staging system.</li><li>➤ Table for TNM Staging:</li><li>➤ Table for TNM Staging:</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1407</li><li>➤ Ref :</li><li>➤ Bailey and Love, 28 th Ed. Pg 1407</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 55-year-old man presents to the clinic with a history of intermittent blood in stools for the past 3 months. After detailed investigations, the surgeon finds a mass at the rectosigmoid junction extending into the upper rectum. There is no nodal or distant metastasis. Which of the following surgeries would you prefer in managing this patient?", "options": [{"label": "A", "text": "Anterior resection (AR)", "correct": true}, {"label": "B", "text": "Left hemicolectomy", "correct": false}, {"label": "C", "text": "Hartman’s procedure", "correct": false}, {"label": "D", "text": "Abdominoperineal resection (APR)", "correct": false}], "correct_answer": "A. Anterior resection (AR)", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Anterior resection (AR)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Left hemicolectomy is performed for tumors of descending colon and sigmoid colon . It does not involve removal of rectum.</li><li>• Option B: Left hemicolectomy</li><li>• performed for tumors of descending colon</li><li>• sigmoid colon</li><li>• Option C: Hartman’s procedure is usually reserved for cases where an anastomosis is not safe to perform , often in emergency settings or when the patient is not fit for a major surgery.</li><li>• Option C: Hartman’s procedure</li><li>• reserved for cases where an anastomosis is not safe to perform</li><li>• Option D: Abdominoperineal resection is performed for lower rectal tumors within 1-2 cm of ano-rectal ring , where a sphincter saving operation is not possible.</li><li>• Option D: Abdominoperineal resection</li><li>• performed for lower rectal tumors within 1-2 cm of ano-rectal ring</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Anterior resection is the preferred surgical treatment for cancers at the rectosigmoid junction , involving the resection of the tumor with a proximal ligation of the vascular pedicle and preservation of the anal sphincter.</li><li>➤ Anterior resection</li><li>➤ surgical treatment for cancers at the rectosigmoid junction</li><li>➤ resection of the tumor</li><li>➤ proximal ligation of the vascular pedicle</li><li>➤ preservation of the anal sphincter.</li><li>➤ When a tumor appears to be locally advanced (i.e. invading a neighboring structure or threatening to breach the circumferential resection margin), the use of neoadjuvant radiotherapy or chemoradiotherapy is usually considered. Long course chemoradiotherapy is given as five fractions of radiotherapy combined with chemotherapy over 6 weeks . The aim is to downstage the cancer and increase the chances of a complete resection with clear oncological margins. Alternatively, preoperative ‘short course’ (5 days) radiotherapy can be used if the resection margins are not threatened but the cancer is still at high risk for local recurrence (e.g., perirectal lymph node involvement)</li><li>➤ When a tumor appears to be locally advanced (i.e. invading a neighboring structure or threatening to breach the circumferential resection margin), the use of neoadjuvant radiotherapy or chemoradiotherapy is usually considered. Long course chemoradiotherapy is given as five fractions of radiotherapy combined with chemotherapy over 6 weeks . The aim is to downstage the cancer and increase the chances of a complete resection with clear oncological margins.</li><li>➤ When a tumor appears to be locally advanced (i.e. invading a neighboring structure or threatening to breach the circumferential resection margin), the use of neoadjuvant radiotherapy or chemoradiotherapy is usually considered. Long course chemoradiotherapy is given as five fractions of radiotherapy combined with chemotherapy over 6 weeks . The aim is to downstage the cancer and increase the chances of a complete resection with clear oncological margins.</li><li>➤ tumor appears to be locally advanced</li><li>➤ five fractions of radiotherapy combined with chemotherapy over 6 weeks</li><li>➤ Alternatively, preoperative ‘short course’ (5 days) radiotherapy can be used if the resection margins are not threatened but the cancer is still at high risk for local recurrence (e.g., perirectal lymph node involvement)</li><li>➤ Alternatively, preoperative ‘short course’ (5 days) radiotherapy can be used if the resection margins are not threatened but the cancer is still at high risk for local recurrence (e.g., perirectal lymph node involvement)</li><li>➤ preoperative ‘short course’</li><li>➤ radiotherapy</li><li>➤ resection margins</li><li>➤ Ref : Bailey and Love, 28 th Ed: Pg 1410</li><li>➤ Ref : Bailey and Love, 28 th Ed: Pg 1410</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In the surgical management of rectal carcinoma, what is the recommended proximal margin of clearance?", "options": [{"label": "A", "text": "5 cm", "correct": true}, {"label": "B", "text": "2 cm", "correct": false}, {"label": "C", "text": "10 cm", "correct": false}, {"label": "D", "text": "7 cm", "correct": false}], "correct_answer": "A. 5 cm", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) 5 cm</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Proximal margin of clearance required in surgery for carcinoma of the rectum is 5 cm.</li><li>• Proximal margin</li><li>• clearance</li><li>• surgery for carcinoma of the rectum is 5 cm.</li><li>• The margins of clearance required for the surgery of rectal carcinoma is :</li><li>• margins of clearance</li><li>• surgery of rectal carcinoma is</li><li>• Proximal - 5 cm Distal - 2 cm to help preserve the anal sphincters When a negative distal margin can be achieved by sparing the sphincter, a sphincter sparing surgery such as low anterior resection (LAR) is performed. If it is not possible to achieve a negative distal margin and spare the sphincter (when the tumor is within 5 cm of anal verge or within 1-2 cm of ano-rectal ring), abdominal perineal resection (APR) is done. Rectosigmoid cancers and those in the upper third of the rectum are removed by ‘high anterior resection’ , in which the rectum and mesorectum are taken to a margin of at least 3 cm distal to the tumour and a colorectal anastomosis is performed. For tumours in the middle and lower thirds of the rectum, complete removal of the rectum and mesorectum is required, i.e. TME (Heald) . Restoration of continuity is usually performed using a stapling technique, which might involve an end-to-end, side-to-end or colo-pouch construction in low cancers.</li><li>• Proximal - 5 cm</li><li>• Proximal - 5 cm</li><li>• Proximal -</li><li>• Distal - 2 cm to help preserve the anal sphincters</li><li>• Distal - 2 cm to help preserve the anal sphincters</li><li>• Distal -</li><li>• When a negative distal margin can be achieved by sparing the sphincter, a sphincter sparing surgery such as low anterior resection (LAR) is performed. If it is not possible to achieve a negative distal margin and spare the sphincter (when the tumor is within 5 cm of anal verge or within 1-2 cm of ano-rectal ring), abdominal perineal resection (APR) is done.</li><li>• When a negative distal margin can be achieved by sparing the sphincter, a sphincter sparing surgery such as low anterior resection (LAR) is performed. If it is not possible to achieve a negative distal margin and spare the sphincter (when the tumor is within 5 cm of anal verge or within 1-2 cm of ano-rectal ring), abdominal perineal resection (APR) is done.</li><li>• negative distal margin</li><li>• low anterior resection (LAR)</li><li>• Rectosigmoid cancers and those in the upper third of the rectum are removed by ‘high anterior resection’ , in which the rectum and mesorectum are taken to a margin of at least 3 cm distal to the tumour and a colorectal anastomosis is performed.</li><li>• Rectosigmoid cancers and those in the upper third of the rectum are removed by ‘high anterior resection’ , in which the rectum and mesorectum are taken to a margin of at least 3 cm distal to the tumour and a colorectal anastomosis is performed.</li><li>• ‘high anterior resection’</li><li>• margin of at least 3 cm distal to the tumour</li><li>• For tumours in the middle and lower thirds of the rectum, complete removal of the rectum and mesorectum is required, i.e. TME (Heald) . Restoration of continuity is usually performed using a stapling technique, which might involve an end-to-end, side-to-end or colo-pouch construction in low cancers.</li><li>• For tumours in the middle and lower thirds of the rectum, complete removal of the rectum and mesorectum is required, i.e. TME (Heald) . Restoration of continuity is usually performed using a stapling technique, which might involve an end-to-end, side-to-end or colo-pouch construction in low cancers.</li><li>• tumours in the middle and lower thirds</li><li>• TME (Heald)</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The standard proximal margin of clearance in rectal cancer surgery is 5 cm , which is necessary to achieve a resection that is free of tumor and to minimize the risk of local recurrence .</li><li>➤ standard proximal margin</li><li>➤ clearance in rectal cancer surgery is 5 cm</li><li>➤ resection that is free of tumor</li><li>➤ minimize the risk of local recurrence</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1410</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1410</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the FALSE statement concerning the surgical principles of rectal cancer?", "options": [{"label": "A", "text": "After anterior resection, Restoration of bowel continuity is usually achieved using a stapled anastomosis.", "correct": false}, {"label": "B", "text": "Hartmann’s operation is used in those patients who have good anal sphincter function", "correct": true}, {"label": "C", "text": "Abdominoperineal resection of the rectum is used for tumors that are very close to the anal sphincter", "correct": false}, {"label": "D", "text": "Endoluminal stenting is performed in patients with obstructive carcinoma", "correct": false}], "correct_answer": "B. Hartmann’s operation is used in those patients who have good anal sphincter function", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Hartmann’s operation is used in those patients who have good anal sphincter function</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: After anterior resection, restoration of bowel continuity is often achieved with a stapled anastomosis . This is a common and accurate method to reconnect the bowel after resection of a portion due to cancer.</li><li>• Option A:</li><li>• After anterior resection, restoration of bowel continuity is often achieved with a stapled anastomosis</li><li>• common and accurate method</li><li>• Option C: Abdominoperineal resection of the rectum is indeed utilized for tumors located very close to the anal sphincter , where sphincter-preserving surgery is not feasible.</li><li>• Option C:</li><li>• Abdominoperineal resection of the rectum</li><li>• utilized for tumors</li><li>• very close to the anal sphincter</li><li>• Option D: Endoluminal stenting is used as a bridge to surgery or as palliative treatment for patients with obstructing carcinoma of the rectum , allowing for the relief of obstruction.</li><li>• Option D:</li><li>• Endoluminal stenting is used as a bridge to surgery</li><li>• palliative treatment</li><li>• obstructing carcinoma of the rectum</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Hartmann’s operation is typically used for patients with poor anal sphincter function , not for those with good sphincter function.</li><li>➤ Hartmann’s operation</li><li>➤ used for patients with poor anal sphincter function</li><li>➤ Abdominoperineal excision of the rectum</li><li>➤ Abdominoperineal excision of the rectum</li><li>➤ This operation is still required for some tumours of the lower third of the rectum that are unsuitable for a sphincter saving procedure.</li><li>➤ Endoluminal stenting</li><li>➤ Endoluminal stenting</li><li>➤ An increasingly used alternative for patients with an obstructing carcinoma is placement of an endoluminal stent, which can be done endoscopically, often with fluoroscopic guidance. This can be used either as a palliative procedure or to relieve obstruction and permit elective rather than emergency surgery to be undertaken.</li><li>➤ palliative procedure or to relieve obstruction</li><li>➤ Surgery for rectal cancer:</li><li>➤ Surgery for rectal cancer:</li><li>➤ Surgery is the mainstay of curative therapy The primary resection consists of rectal resection performed by TME(total meso-rectal excision). Early cancers (stages T1 and selected T2) may be suitable for local excision Most cases can be treated by anterior resection, with a colorectal or coloanal anastomosis being achieved with a circular stapling device Low, extensive tumours require an abdominoperineal excision with a permanent colostomy Neoadjuvant chemoradiotherapy can be used to downstage the cancer and reduce local recurrence ‘Watch and wait’ non-operative management is an option for the 20% who have a complete clinical response to neoadjuvant chemoradiotherapy</li><li>➤ Surgery is the mainstay of curative therapy</li><li>➤ mainstay of curative therapy</li><li>➤ The primary resection consists of rectal resection performed by TME(total meso-rectal excision).</li><li>➤ Early cancers (stages T1 and selected T2) may be suitable for local excision</li><li>➤ Most cases can be treated by anterior resection, with a colorectal or coloanal anastomosis being achieved with a circular stapling device</li><li>➤ Low, extensive tumours require an abdominoperineal excision with a permanent colostomy</li><li>➤ Neoadjuvant chemoradiotherapy can be used to downstage the cancer and reduce local recurrence</li><li>➤ ‘Watch and wait’ non-operative management is an option for the 20% who have a complete clinical response to neoadjuvant chemoradiotherapy</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1412-1414</li><li>➤ Ref :</li><li>➤ Bailey and Love, 28 th Ed. Pg 1412-1414</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In the image provided, which transanal surgical technique is depicted, often used for organ-preserving excision in early-stage rectal cancer?", "options": [{"label": "A", "text": "Stapled hemorrhoidectomy", "correct": false}, {"label": "B", "text": "STARR", "correct": false}, {"label": "C", "text": "TaTME", "correct": true}, {"label": "D", "text": "VAAFT", "correct": false}], "correct_answer": "C. TaTME", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/untitled-582.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) TaTME</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Stapled hemorrhoidectomy is a procedure used to treat hemorrhoids and is not typically indicated for rectal cancer. It involves the resection of excessive hemorrhoidal tissue using a circular stapling device.</li><li>• Option A: Stapled hemorrhoidectomy</li><li>• procedure used to treat hemorrhoids</li><li>• Option B: STARR stands for Stapled Transanal Rectal Resection , which is a procedure for obstructed defecation syndrome but is not typically used for rectal cancer.</li><li>• Option B: STARR</li><li>• Stapled Transanal Rectal Resection</li><li>• Option D: VAAFT stands for Video-Assisted Anal Fistula Treatment , which is a technique used for the surgical treatment of fistulas, not rectal cancer.</li><li>• Option D: VAAFT</li><li>• Video-Assisted Anal Fistula Treatment</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The depicted procedure is TaTME , a minimally invasive technique used for the precise and full-thickness excision of rectal cancer , preserving organ integrity when possible.</li><li>➤ TaTME</li><li>➤ minimally invasive technique</li><li>➤ precise and full-thickness excision of rectal cancer</li><li>➤ organ integrity</li><li>➤ Ref : Bailey 28 th and Love, Ed. Pg 1409-1411</li><li>➤ Ref : Bailey 28 th and Love, Ed. Pg 1409-1411</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "During anterior resection of rectal cancer, injury to the pelvic plexus (Nervi erigentes) during lateral dissection will lead to which of the following?", "options": [{"label": "A", "text": "Retrograde ejaculation", "correct": false}, {"label": "B", "text": "Impotence", "correct": true}, {"label": "C", "text": "Spastic urinary bladder", "correct": false}, {"label": "D", "text": "Sensory loss over medial thigh", "correct": false}], "correct_answer": "B. Impotence", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Impotence</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Retrograde ejaculation will occur due to damage to sympathetic plexus , which occurs due to high ligation of IMA.</li><li>• Option A: Retrograde ejaculation</li><li>• damage to sympathetic plexus</li><li>• Option C: Due to parasympathetic damage , bladder will become atonic , not spastic.</li><li>• Option C:</li><li>• parasympathetic damage</li><li>• bladder will become atonic</li><li>• Option D: Sensory loss is not a feature of pelvic plexus injury , as it is under spinal nerve control.</li><li>• Option D: Sensory loss</li><li>• not a feature of pelvic plexus injury</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• During Rectal resection:</li><li>• During Rectal resection:</li><li>• 1 . If IMA is ligated at the root:</li><li>• 1</li><li>• If IMA is ligated at the root:</li><li>• Injury to hypogastric plexus-&gt; Lumbar sympathetic damaged</li><li>• This will lead to retrograde ejaculation. (Option A)</li><li>• 2 . During lateral dissection:</li><li>• 2</li><li>• During lateral dissection:</li><li>• Injury to pelvic plexus/Nervi erigentes--&gt; Parasympathetics damaged. This will lead to impotence/erectile dysfunction and atonic bladder. (option B and C)</li><li>• 3 . During anterior dissection:</li><li>• 3</li><li>• During anterior dissection:</li><li>• Injury to periprostatic plexus--&gt; bladder and sexual dysfunction.</li><li>• Ref : Sabiston 21st Ed., Pg 1329</li><li>• Ref :</li><li>• Sabiston 21st Ed., Pg 1329</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 35-year-old Female patient presented to the OPD with severe pain during defecation and with complaints of “blood streaking the stools''. P/R examination showed severe anal spasm. What is your probable diagnosis?", "options": [{"label": "A", "text": "Hemorrhoids", "correct": false}, {"label": "B", "text": "Peri anal abscess", "correct": false}, {"label": "C", "text": "Fistula-in-ano", "correct": false}, {"label": "D", "text": "Fissure-in-ano", "correct": true}], "correct_answer": "D. Fissure-in-ano", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Hemorrhoids: Hemorrhoids may cause painless bleeding unless thrombosed or prolapsed.</li><li>• Option A. Hemorrhoids:</li><li>• painless bleeding</li><li>• Option B. Perianal abscess: A perianal abscess would present with severe, constant pain, erythema, and swelling near the anus , and potentially fever , rather than pain specifically during defecation.</li><li>• Option B. Perianal abscess:</li><li>• severe, constant pain, erythema, and swelling near the anus</li><li>• fever</li><li>• Option C. Fistula-in-ano: Fistula-in-ano usually presents with chronic discharge and may cause discomfort but not the acute , severe pain during defecation characteristic of an anal fissure.</li><li>• Option C. Fistula-in-ano:</li><li>• chronic discharge</li><li>• cause discomfort but not the acute</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The presentation of severe pain during defecation , anal spasm , and blood streaking on toilet paper is typical of an anal fissure . Treatment options include conservative measures such as increased dietary fiber , stool softeners , topical anesthetics , and vasodilators like nitroglycerin ointment . In refractory cases, lateral internal sphincterotomy or botulinum toxin injection may be required.</li><li>➤ severe pain during defecation</li><li>➤ anal spasm</li><li>➤ blood streaking on toilet paper</li><li>➤ typical of an anal fissure</li><li>➤ Treatment</li><li>➤ conservative measures such as increased dietary fiber</li><li>➤ stool softeners</li><li>➤ topical anesthetics</li><li>➤ vasodilators</li><li>➤ nitroglycerin ointment</li><li>➤ Although superficial, acute anal fissures are characterized by severe anal pain during defecation (‘passing glass’ or ‘a knife cutting’) , which usually resolves only to recur at the next evacuation. Frequently a trace of fresh blood is noticed on tissue paper after wiping. Chronic fissures are characterized by a hypertrophied anal papilla internally and a sentinel tag externally. Treatment: Conservative management should result in the healing of almost all acute and the majority of chronic fissures. Emphasis must be placed on the normalization of bowel habits. The addition of fiber to the diet to bulk up the stool, stool softeners, and adequate water intake are simple and helpful measures. Warm baths and topical local anesthetic agents relieve pain. Glyceryl trinitrate (GTN) (0.2% applied two or three times per day to the anal margin) is a nitric oxide donor while diltiazem (2% applied twice daily) is a calcium channel antagonist. Botulinum toxin (10–100 units) injected into the internal sphincter reduces anal canal pressure. Lateral internal sphincterotomy: The internal sphincter is divided away from the fissure itself – usually either in the right or the left lateral positions. Healing rates are in the range of 85%, but there is also a significant risk of altered continence An anal advancement flap to cover the anal fissure should be considered in those with an increased risk of altered continence following lateral internal sphincterotomy, especially in postpartum women and those with normal or low resting anal pressures.</li><li>➤ Although superficial, acute anal fissures are characterized by severe anal pain during defecation (‘passing glass’ or ‘a knife cutting’) , which usually resolves only to recur at the next evacuation. Frequently a trace of fresh blood is noticed on tissue paper after wiping.</li><li>➤ (‘passing glass’ or ‘a knife cutting’)</li><li>➤ Chronic fissures are characterized by a hypertrophied anal papilla internally and a sentinel tag externally.</li><li>➤ hypertrophied anal papilla internally and a sentinel tag externally.</li><li>➤ Treatment: Conservative management should result in the healing of almost all acute and the majority of chronic fissures. Emphasis must be placed on the normalization of bowel habits. The addition of fiber to the diet to bulk up the stool, stool softeners, and adequate water intake are simple and helpful measures. Warm baths and topical local anesthetic agents relieve pain.</li><li>➤ Treatment:</li><li>➤ Glyceryl trinitrate (GTN) (0.2% applied two or three times per day to the anal margin) is a nitric oxide donor while diltiazem (2% applied twice daily) is a calcium channel antagonist. Botulinum toxin (10–100 units) injected into the internal sphincter reduces anal canal pressure.</li><li>➤ Glyceryl trinitrate</li><li>➤ diltiazem</li><li>➤ Botulinum toxin</li><li>➤ Lateral internal sphincterotomy: The internal sphincter is divided away from the fissure itself – usually either in the right or the left lateral positions. Healing rates are in the range of 85%, but there is also a significant risk of altered continence</li><li>➤ Lateral internal sphincterotomy:</li><li>➤ An anal advancement flap to cover the anal fissure should be considered in those with an increased risk of altered continence following lateral internal sphincterotomy, especially in postpartum women and those with normal or low resting anal pressures.</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1428</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1428</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A newborn is found to have a pathology for which an imaging is done as below. Which of the following additional anomalies is least likely to be associated with this condition, considering the common associations of the pathology?", "options": [{"label": "A", "text": "Tracheo-esophageal fistula", "correct": false}, {"label": "B", "text": "Missing forearm bones", "correct": false}, {"label": "C", "text": "Wilms’ tumor", "correct": true}, {"label": "D", "text": "Hemi-vertebrae", "correct": false}], "correct_answer": "C. Wilms’ tumor", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture5_lUloloi.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. T-E fistula: Tracheoesophageal fistula is part of the VACTERL association , which includes vertebral defects , anorectal malformations , cardiac defects, tracheoesophageal fistula, renal anomalies, and limb abnormalities.</li><li>• Option A. T-E fistula:</li><li>• Tracheoesophageal fistula</li><li>• VACTERL association</li><li>• vertebral defects</li><li>• anorectal malformations</li><li>• Option B. Missing forearm bones: Limb anomalies , such as missing bones , are also part of the VACTERL association and could coexist with ARM.</li><li>• Option B. Missing forearm bones:</li><li>• Limb anomalies</li><li>• missing bones</li><li>• Option D. Hemi-vertebrae: Vertebral anomalies , such as hemi-vertebrae , are part of the spectrum of abnormalities that may present with ARM as part of the VACTERL association.</li><li>• Option D. Hemi-vertebrae:</li><li>• Vertebral anomalies</li><li>• hemi-vertebrae</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Anorectal malformation in a newborn is commonly associated with other anomalies as part of the VACTERL association , including tracheoesophageal fistula , limb anomalies like missing bones , and vertebral anomalies such as hemi-vertebrae . Wilms' tumor, however, is not commonly a part of this association.Top of Form</li><li>➤ Anorectal malformation</li><li>➤ newborn</li><li>➤ associated with other anomalies</li><li>➤ part of the VACTERL association</li><li>➤ tracheoesophageal fistula</li><li>➤ limb anomalies</li><li>➤ missing bones</li><li>➤ vertebral anomalies such as hemi-vertebrae</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 263</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th Ed. Pg 263</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old male presented with something coming out per anus (SCOPA) and splash in the pan type of blood in stools. On examination, the mass remains outside and has crossed the anal verge but can be manually reduced. Which is the grade of the disease?", "options": [{"label": "A", "text": "1", "correct": false}, {"label": "B", "text": "2", "correct": false}, {"label": "C", "text": "3", "correct": true}, {"label": "D", "text": "4", "correct": false}], "correct_answer": "C. 3", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) 3</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation :</li><li>• Hemorrhoids are symptomatic enlargements of the internal haemorrhoidal venous plexus (Greek: haima = blood, rhoos = flowing; synonym: piles, Latin: pila = a ball). Internal hemorrhoids characteristically lie in the 3, 7, and 11 o’clock positions (with the patient in the lithotomy position) The internal haemorrhoidal plexus constitutes the submucosal component of the anal cushions that are important in sealing the anal canal . Man’s upright posture, the absence of valves in the portal venous system and raised abdominal pressure due to pregnancy or particularly through straining during defecation contribute to venous plexus engorgement and development of varicosities . Shearing forces lead to mucosal trauma (bleeding) and caudal displacement of the anal cushions (prolapse).</li><li>• Hemorrhoids are symptomatic enlargements of the internal haemorrhoidal venous plexus (Greek: haima = blood, rhoos = flowing; synonym: piles, Latin: pila = a ball). Internal hemorrhoids characteristically lie in the 3, 7, and 11 o’clock positions (with the patient in the lithotomy position)</li><li>• Hemorrhoids are symptomatic enlargements of the internal haemorrhoidal venous plexus (Greek: haima = blood, rhoos = flowing; synonym: piles, Latin: pila = a ball). Internal hemorrhoids characteristically lie in the 3, 7, and 11 o’clock positions (with the patient in the lithotomy position)</li><li>• Hemorrhoids are symptomatic enlargements</li><li>• internal haemorrhoidal venous plexus</li><li>• Internal hemorrhoids characteristically lie in the 3, 7, and 11 o’clock positions</li><li>• The internal haemorrhoidal plexus constitutes the submucosal component of the anal cushions that are important in sealing the anal canal . Man’s upright posture, the absence of valves in the portal venous system and raised abdominal pressure due to pregnancy or particularly through straining during defecation contribute to venous plexus engorgement and development of varicosities . Shearing forces lead to mucosal trauma (bleeding) and caudal displacement of the anal cushions (prolapse).</li><li>• The internal haemorrhoidal plexus constitutes the submucosal component of the anal cushions that are important in sealing the anal canal . Man’s upright posture, the absence of valves in the portal venous system and raised abdominal pressure due to pregnancy or particularly through straining during defecation contribute to venous plexus engorgement and development of varicosities . Shearing forces lead to mucosal trauma (bleeding) and caudal displacement of the anal cushions (prolapse).</li><li>• internal haemorrhoidal plexus</li><li>• submucosal component of the anal cushions</li><li>• sealing the anal canal</li><li>• venous plexus engorgement and development of varicosities</li><li>• Four degrees of hemorrhoids:</li><li>• Four degrees of hemorrhoids:</li><li>• First degree - Bleed only, no prolapse Second degree - Prolapse but reduce spontaneously Third degree - Prolapse but have to be manually reduced Fourth degree - Permanently prolapsed</li><li>• First degree - Bleed only, no prolapse</li><li>• First degree - Bleed only, no prolapse</li><li>• First degree</li><li>• Second degree - Prolapse but reduce spontaneously</li><li>• Second degree - Prolapse but reduce spontaneously</li><li>• Second degree</li><li>• Third degree - Prolapse but have to be manually reduced</li><li>• Third degree - Prolapse but have to be manually reduced</li><li>• Third degree</li><li>• Fourth degree - Permanently prolapsed</li><li>• Fourth degree - Permanently prolapsed</li><li>• Fourth degree</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Grade III internal hemorrhoids are characterized by prolapse during straining or defecation that can be manually reduced , distinguishing them from Grade IV , which are irreducible .</li><li>➤ Grade III internal hemorrhoids</li><li>➤ prolapse during straining or defecation</li><li>➤ manually reduced</li><li>➤ distinguishing them from Grade IV</li><li>➤ irreducible</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1430</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1430</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 35-year-old female presents with bleeding during defecation and straining. Examination reveals pile mass which appears on straining, at 7 and 11 O'clock, and reduces spontaneously. Preferred treatment?", "options": [{"label": "A", "text": "Barron’s Banding", "correct": true}, {"label": "B", "text": "Stapled hemorrhoidopexy", "correct": false}, {"label": "C", "text": "Milligan Morgan procedure", "correct": false}, {"label": "D", "text": "Sitz bath", "correct": false}], "correct_answer": "A. Barron’s Banding", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture10_CP9AOR1.jpg"], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. Stapled hemorrhoidopexy: This surgical procedure is generally reserved for more severe hemorrhoids , typically prolapsed or third-degree hemorrhoids that do not respond to other treatments.</li><li>• Option B. Stapled hemorrhoidopexy:</li><li>• reserved for more severe hemorrhoids</li><li>• prolapsed or third-degree hemorrhoids</li><li>• Option C. Milligan Morgan procedure: This is an open surgical technique for hemorrhoidectomy, usually indicated for third and fourth-degree hemorrhoids , or second-degree hemorrhoids that have not responded to non-operative treatments.</li><li>• Option C. Milligan Morgan procedure:</li><li>• open surgical technique for hemorrhoidectomy,</li><li>• third and fourth-degree hemorrhoids</li><li>• Option D. Sitz bath: While a Sitz bath can relieve symptoms , it is not a definitive treatment for hemorrhoids that are not responsive to conservative management.</li><li>• Option D. Sitz bath:</li><li>• relieve symptoms</li><li>• definitive treatment for hemorrhoids</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ For reducible first and second-degree internal hemorrhoids that are not responsive to conservative measures , Barron’s Banding is an effective initial treatment before considering surgical options.</li><li>➤ reducible first and second-degree internal hemorrhoids</li><li>➤ conservative measures</li><li>➤ Barron’s Banding</li><li>➤ initial treatment</li><li>➤ In patients with first or second-degree internal haemorrhoids whose symptoms are not improved by conservative measures, injection sclerotherapy with submucosal injection of 5% phenol in arachis oil or almond oil may be used. It is important to inject about 3-5 mL of sclerosant into the apex of the pedicle and not into the haemorrhoid itself using a disposable needle and syringe. Injections placed too deeply can have serious consequences, including prostatitis and pelvic sepsis. For this reason, haemorrhoidal injection has largely been superseded by rubber band ligation. The Barron’s bander is a commonly available device used to slip tight elastic bands onto the base of the pedicle of each hemorrhoid. The band must be applied above the dentate line as below can cause intense pain. The bands cause ischaemic necrosis of the piles, which slough off within 10 days ; this may be associated with bleeding, about which the patient must be warned</li><li>➤ In patients with first or second-degree internal haemorrhoids whose symptoms are not improved by conservative measures, injection sclerotherapy with submucosal injection of 5% phenol in arachis oil or almond oil may be used.</li><li>➤ first or second-degree internal haemorrhoids</li><li>➤ injection sclerotherapy with submucosal injection of 5% phenol in arachis oil or almond oil</li><li>➤ It is important to inject about 3-5 mL of sclerosant into the apex of the pedicle and not into the haemorrhoid itself using a disposable needle and syringe. Injections placed too deeply can have serious consequences, including prostatitis and pelvic sepsis.</li><li>➤ Injections placed too deeply can have serious consequences, including prostatitis and pelvic sepsis.</li><li>➤ For this reason, haemorrhoidal injection has largely been superseded by rubber band ligation. The Barron’s bander is a commonly available device used to slip tight elastic bands onto the base of the pedicle of each hemorrhoid. The band must be applied above the dentate line as below can cause intense pain. The bands cause ischaemic necrosis of the piles, which slough off within 10 days ; this may be associated with bleeding, about which the patient must be warned</li><li>➤ Barron’s bander</li><li>➤ The bands cause ischaemic necrosis of the piles, which slough off within 10 days</li><li>➤ The indications for haemorrhoidectomy include:</li><li>➤ The indications for haemorrhoidectomy include:</li><li>➤ Third and fourth-degree haemorrhoids Second-degree hemorrhoids that have not been cured by on-operative treatments; ‘Mixed’ hemorrhoids when the external hemorrhoid is well defined; Bleeding causing anaemia.</li><li>➤ Third and fourth-degree haemorrhoids</li><li>➤ Second-degree hemorrhoids that have not been cured by on-operative treatments;</li><li>➤ ‘Mixed’ hemorrhoids when the external hemorrhoid is well defined;</li><li>➤ Bleeding causing anaemia.</li><li>➤ This can be done by:</li><li>➤ This can be done by:</li><li>➤ Open technique of Milligan Morgan Closed technique of Ferguson Stapled technique of Longo</li><li>➤ Open technique of Milligan Morgan</li><li>➤ Closed technique of Ferguson</li><li>➤ Stapled technique of Longo</li><li>➤ Ref : Bailey and Love 28th Ed. Pg 1431-32</li><li>➤ Ref</li><li>➤ : Bailey and Love 28th Ed. Pg 1431-32</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 30-year-old male presents with a 6-month history of perianal discomfort and purulent discharge. On physical examination, there is induration in the perianal region, suggestive of a chronic fistula-in-ano. No external openings are visible. The surgical team is considering the best imaging modality to delineate the anatomy of the suspected fistulous tract and any potential secondary extensions before proceeding with surgery. What is the investigation of choice in this case?", "options": [{"label": "A", "text": "MRI", "correct": true}, {"label": "B", "text": "CECT abdomen pelvis", "correct": false}, {"label": "C", "text": "Proctoscopy", "correct": false}, {"label": "D", "text": "Sigmoidoscopy", "correct": false}], "correct_answer": "A. MRI", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. CECT abdomen pelvis can be helpful in certain abdominal pathologies but is less sensitive than MRI for the soft tissue detail needed in anal fistulae.</li><li>• Option B. CECT abdomen pelvis</li><li>• helpful in certain abdominal pathologies</li><li>• Option C. Proctoscopy is a direct visualization technique that can be useful for assessing the internal orifice and local inflammation but does not provide information about the full extent of the fistula tract.</li><li>• Option C. Proctoscopy</li><li>• direct visualization technique</li><li>• useful for assessing the internal orifice</li><li>• Option D. Sigmoidoscopy is utilized to visualize the sigmoid colon and may be useful in excluding other colonic pathologies but not as first-line imaging for a fistula-in-ano.</li><li>• Option D. Sigmoidoscopy</li><li>• visualize the sigmoid colon</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ MRI is the imaging modality of choice for evaluating fistula-in-ano due to its ability to delineate the anatomy of the fistulous tract and identify any secondary extensions , which is essential for effective surgical management.</li><li>➤ MRI is the imaging modality</li><li>➤ evaluating fistula-in-ano</li><li>➤ ability to delineate the anatomy of the fistulous tract</li><li>➤ secondary extensions</li><li>➤ effective surgical management.</li><li>➤ Fistulography and computed tomography (CT) are useful if an extra-sphincteric fistula is suspected.</li><li>➤ Fistulography and computed tomography (CT) are useful if an extra-sphincteric fistula is suspected.</li><li>➤ Fistulography and computed tomography</li><li>➤ extra-sphincteric fistula</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1438</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1438</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 40-year-old male presents with recurrent perianal abscesses and purulent drainage noted at the 6 o'clock position in relation to the anus. He reports intermittent discomfort and swelling in the perianal region that seems to temporarily improve with antibiotics but has recurred several times. On examination, an external opening is noted in the perianal skin with induration suggestive of a chronic fistulous tract. The patient expresses his desire for a definitive treatment that would minimize the risk of incontinence. Which of the following is not a treatment option for fistula in ano?", "options": [{"label": "A", "text": "Cutting setons", "correct": false}, {"label": "B", "text": "LIFT", "correct": false}, {"label": "C", "text": "VAAFT", "correct": false}, {"label": "D", "text": "Internal sphincterotomy", "correct": true}], "correct_answer": "D. Internal sphincterotomy", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Cutting setons: This involves placing a seton (thread or wire) to gradually cut through the fistulous tract over time , allowing for healing from the inside out . It is used for complex or high fistulas to avoid significant sphincter damage in one operation.</li><li>• Option A. Cutting setons:</li><li>• placing a seton</li><li>• gradually cut through the fistulous tract over time</li><li>• healing from the inside out</li><li>• Option B. LIFT: A minimally invasive technique that aims to preserve sphincter function . The intersphincteric fistula tract is ligated and divided at the intersphincteric plane without disturbing the sphincter muscles.</li><li>• Option B. LIFT:</li><li>• minimally invasive technique</li><li>• preserve sphincter function</li><li>• intersphincteric fistula tract</li><li>• ligated and divided at the intersphincteric plane</li><li>• Option C. VAAFT: This endoscopic technique allows the surgeon to see inside the fistula tract and to cauterize or excise the tract with minimal disruption to the sphincter muscles.</li><li>• Option C. VAAFT:</li><li>• endoscopic technique</li><li>• allows the surgeon</li><li>• see inside the fistula tract</li><li>• cauterize or excise the tract</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Internal sphincterotomy is not generally recommended for treating trans-sphincteric fistulas but for acute fissure in ano . The correct management would involve methods that aim to preserve sphincter integrity while adequately addressing the fistula .</li><li>➤ Internal sphincterotomy</li><li>➤ not generally recommended for treating trans-sphincteric fistulas</li><li>➤ acute fissure in ano</li><li>➤ methods that aim to preserve sphincter integrity</li><li>➤ addressing the fistula</li><li>➤ Surgery for fistula-in-ano:</li><li>➤ Surgery for fistula-in-ano:</li><li>➤ Fistulotomy involves division of all structures lying between the external and internal openings. It is therefore applied mainly to intersphincteric fistula and trans-sphincteric fistulae involving less than 30% of the external sphincter (but not anterior fistulae in women) Fistulectomy involves coring out of the fistula, usually by diathermy cautery; it allows a better definition of fistula anatomy than fistulotomy, especially the level at which the track crosses the sphincters and the presence of secondary extensions. Loose setons are tied such that there is no tension upon the encircled tissue; there is no intent to cut the tissue. A variety of materials have been used but the seton should be non-absorbable, non-degenerative, and comfortable . Tight or cutting setons are placed with the intention of cutting through the enclosed muscle. Loose setons are also used for long-term palliation to avoid septic and painful exacerbations by establishing effective drainage Cutting setons aim to achieve the high fistula eradication rates associated with fistulotomy but without the degree of functional impairment endowed by division of the sphincters at a single stage. LIFT (Ligation of inter-sphincteric fistula tract) :</li><li>➤ Fistulotomy involves division of all structures lying between the external and internal openings. It is therefore applied mainly to intersphincteric fistula and trans-sphincteric fistulae involving less than 30% of the external sphincter (but not anterior fistulae in women)</li><li>➤ Fistulotomy</li><li>➤ (but not anterior fistulae in women)</li><li>➤ Fistulectomy involves coring out of the fistula, usually by diathermy cautery; it allows a better definition of fistula anatomy than fistulotomy, especially the level at which the track crosses the sphincters and the presence of secondary extensions.</li><li>➤ Fistulectomy</li><li>➤ Loose setons are tied such that there is no tension upon the encircled tissue; there is no intent to cut the tissue. A variety of materials have been used but the seton should be non-absorbable, non-degenerative, and comfortable . Tight or cutting setons are placed with the intention of cutting through the enclosed muscle. Loose setons are also used for long-term palliation to avoid septic and painful exacerbations by establishing effective drainage</li><li>➤ Loose setons</li><li>➤ seton should be non-absorbable, non-degenerative, and comfortable</li><li>➤ Cutting setons aim to achieve the high fistula eradication rates associated with fistulotomy but without the degree of functional impairment endowed by division of the sphincters at a single stage.</li><li>➤ Cutting setons</li><li>➤ LIFT (Ligation of inter-sphincteric fistula tract) :</li><li>➤ LIFT</li><li>➤ :</li><li>➤ LIFT involves disconnection of the internal opening from the fistula tract at the level of the inter-sphincteric plane and removal of the residual infected glands without dividing any part of the sphincter complex. The tract is then ligated and divided, the internal part is removed and the external part of the track is curetted and drained.</li><li>➤ LIFT</li><li>➤ disconnection of the internal opening</li><li>➤ fistula tract at the level of the inter-sphincteric plane</li><li>➤ removal of the residual infected glands</li><li>➤ VAAFT (Video-assisted anal fistula tract excision) :</li><li>➤ VAAFT (Video-assisted anal fistula tract excision) :</li><li>➤ VAAFT</li><li>➤ :</li><li>➤ The procedure involves the use of a special endoscope equipped with a camera and a laser fiber to visualize and remove the fistula tract while preserving the sphincter muscles. The advantage of VAAFT is that it offers a high success rate, minimal pain, and faster recovery compared to traditional surgical techniques.</li><li>➤ procedure involves the use of a special endoscope equipped with a camera</li><li>➤ laser fiber to visualize</li><li>➤ remove the fistula tract</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1440</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1440</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the structure numbered 11 in the image?", "options": [{"label": "A", "text": "Levator ani", "correct": false}, {"label": "B", "text": "Internal sphincter", "correct": true}, {"label": "C", "text": "External sphincter", "correct": false}, {"label": "D", "text": "Circular muscle of rectum", "correct": false}], "correct_answer": "B. Internal sphincter", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture1_fBqWO0h.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Levator ani includes the iliococcygeus and puborectalis muscles , which form part of the pelvic floor and contribute to the maintenance of fecal continence by providing structural support to the rectum and anal canal.</li><li>• Option A.</li><li>• Levator ani</li><li>• iliococcygeus and puborectalis muscles</li><li>• form part of the pelvic floor</li><li>• Option C. External sphincter consists of the deep, superficial, and subcutaneous parts and is under voluntary control.</li><li>• Option C.</li><li>• External sphincter</li><li>• deep, superficial, and subcutaneous parts</li><li>• Option D. Circular muscle of rectum is part of the muscular structure of the rectum , which is distinct from the internal anal sphincter</li><li>• Option D.</li><li>• Circular muscle of rectum</li><li>• muscular structure of the rectum</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The internal anal sphincter is labeled as number 11 in anatomical diagrams of the anal canal and is identified as a thickened distal continuation of the circular muscle layer of the rectum , functioning involuntarily .</li><li>➤ internal anal sphincter is labeled as number 11</li><li>➤ anal canal</li><li>➤ thickened distal continuation of the circular muscle layer</li><li>➤ rectum</li><li>➤ involuntarily</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg. 1418</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg. 1418</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the incorrect statement.", "options": [{"label": "A", "text": "Internal sphincter injury doesn’t lead to fecal incontinence if external sphincter is intact", "correct": false}, {"label": "B", "text": "Internal sphincter is a continuation of the circular muscle coat of the rectum", "correct": false}, {"label": "C", "text": "Anal canal is derived entirely from proctodaeum", "correct": true}, {"label": "D", "text": "Part of the anus above the dentate line lacks sensations", "correct": false}], "correct_answer": "C. Anal canal is derived entirely from proctodaeum", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture2_zuorhIA.jpg"], "explanation": "<p><strong>Ans. C) Anal canal is derived entirely from proctodaeum</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. is correct: The internal sphincter , made up of smooth muscle, contributes to some amount continence at rest . Injury to this sphincter doesn’t indeed lead to fecal incontinence, if external sphincter is intact.</li><li>• Option A. is correct:</li><li>• internal sphincter</li><li>• smooth muscle,</li><li>• some amount continence at rest</li><li>• Option B. is correct: The internal sphincter is the thickened (2–5 mm) distal continuation of the circular muscle layer of the rectum.</li><li>• Option B. is correct:</li><li>• internal sphincter</li><li>• Option D. is correct: The part of the anus above the dentate line lacks sensations such as pain and temperature because it is innervated by visceral sensory fibers, unlike the area below the dentate line, which has somatic innervation.</li><li>• Option D. is correct:</li><li>• part of the anus above the dentate line lacks sensations</li><li>• pain and temperature</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The incorrect statement is that the anal canal is not entirely derived from the proctodeum; it has a dual embryonic origin, with the part above the dentate line being endodermal and the part below being ectodermal.</li><li>➤ incorrect statement</li><li>➤ anal canal</li><li>➤ not entirely derived from the proctodeum;</li><li>➤ dual embryonic origin,</li><li>➤ dentate line being endodermal</li><li>➤ part below being ectodermal.</li><li>➤ The internal sphincter is the thickened (2–5 mm) distal continuation of the circular muscle layer of the rectum. This involuntary muscle commences where the rectum passes through the pelvic diaphragm and ends above the anal orifice, its lower border palpable at the inter-sphincteric groove The external sphincter forms the bulk of the anal sphincter complex . It is a single muscle (Goligher), which is variably divided by lateral extensions from the longitudinal muscle layer. Some of the fibers are attached to the coccyx posteriorly, whereas anteriorly they fuse with the perineal muscles. Being a somatic voluntary muscle, the external sphincter is red in color. The row of alternating columns and crypts gives a serrated appearance known as the dentate line , which is considered to be the embryological junction between the endodermal and ectodermal parts of the anal canal (the proctodaeum). Below the dentate line, the anoderm is lined by non-keratinised stratified squamous epithelium that is devoid of glands and hair but richly innervated by somatic sensory nerve endings</li><li>➤ The internal sphincter is the thickened (2–5 mm) distal continuation of the circular muscle layer of the rectum. This involuntary muscle commences where the rectum passes through the pelvic diaphragm and ends above the anal orifice, its lower border palpable at the inter-sphincteric groove</li><li>➤ The internal sphincter is the thickened (2–5 mm) distal continuation of the circular muscle layer of the rectum. This involuntary muscle commences where the rectum passes through the pelvic diaphragm and ends above the anal orifice, its lower border palpable at the inter-sphincteric groove</li><li>➤ internal sphincter</li><li>➤ its lower border palpable at the inter-sphincteric groove</li><li>➤ The external sphincter forms the bulk of the anal sphincter complex . It is a single muscle (Goligher), which is variably divided by lateral extensions from the longitudinal muscle layer. Some of the fibers are attached to the coccyx posteriorly, whereas anteriorly they fuse with the perineal muscles. Being a somatic voluntary muscle, the external sphincter is red in color.</li><li>➤ The external sphincter forms the bulk of the anal sphincter complex . It is a single muscle (Goligher), which is variably divided by lateral extensions from the longitudinal muscle layer. Some of the fibers are attached to the coccyx posteriorly, whereas anteriorly they fuse with the perineal muscles. Being a somatic voluntary muscle, the external sphincter is red in color.</li><li>➤ external sphincter forms the bulk of the anal sphincter complex</li><li>➤ The row of alternating columns and crypts gives a serrated appearance known as the dentate line , which is considered to be the embryological junction between the endodermal and ectodermal parts of the anal canal (the proctodaeum).</li><li>➤ The row of alternating columns and crypts gives a serrated appearance known as the dentate line , which is considered to be the embryological junction between the endodermal and ectodermal parts of the anal canal (the proctodaeum).</li><li>➤ dentate line</li><li>➤ the embryological junction between the endodermal and ectodermal</li><li>➤ Below the dentate line, the anoderm is lined by non-keratinised stratified squamous epithelium that is devoid of glands and hair but richly innervated by somatic sensory nerve endings</li><li>➤ Below the dentate line, the anoderm is lined by non-keratinised stratified squamous epithelium that is devoid of glands and hair but richly innervated by somatic sensory nerve endings</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1418</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1418</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In which of the following conditions is the use of the given instrument is contraindicated?", "options": [{"label": "A", "text": "Haemorrhoids", "correct": false}, {"label": "B", "text": "Anal canal biopsy", "correct": false}, {"label": "C", "text": "Anal fissure", "correct": true}, {"label": "D", "text": "Rectal polyp", "correct": false}], "correct_answer": "C. Anal fissure", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture3_d4qpMsq.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Haemorrhoids: A proctoscope can be used to evaluate and treat hemorrhoids . It allows for the visualization of the anal canal and can assist in procedures such as rubber band ligation.</li><li>• Option A. Haemorrhoids:</li><li>• proctoscope</li><li>• evaluate and treat hemorrhoids</li><li>• allows for the visualization</li><li>• anal canal</li><li>• Option B. Anal canal biopsy: The proctoscope is an appropriate tool for visualizing the anal canal to obtain biopsy samples from suspicious areas within the canal.</li><li>• Option B. Anal canal biopsy:</li><li>• proctoscope is an appropriate tool for visualizing the anal canal</li><li>• Option D. Rectal polyp: Proctoscopy can be used to visualize and potentially remove polyps within the rectum , especially those close to the anal canal.</li><li>• Option D. Rectal polyp:</li><li>• Proctoscopy</li><li>• used to visualize</li><li>• potentially remove polyps within the rectum</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The use of a proctoscope is contraindicated in the presence of an acute anal fissure due to the severe pain it may cause during the examination.</li><li>➤ use of a proctoscope</li><li>➤ presence of an acute anal fissure</li><li>➤ severe pain</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A newborn male has failed to pass meconium since birth and presents with the absence of a normal anal opening. Which of the following statements regarding this condition is incorrect?", "options": [{"label": "A", "text": "Imperforate anus is a type of Low Ano-rectal malformation (ARM)", "correct": false}, {"label": "B", "text": "High ARMs may result in the formulation of a persistent cloaca in females", "correct": false}, {"label": "C", "text": "In boys, a recto-vesical fistula is the most common type", "correct": true}, {"label": "D", "text": "Imperforate anus is treated by anoplasty", "correct": false}], "correct_answer": "C. In boys, a recto-vesical fistula is the most common type", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture4_FCFHyCX.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Imperforate anus is indeed a type of low ARM, where there is an anal membrane or anal stenosis.</li><li>• Option A.</li><li>• Imperforate anus is indeed a type of low ARM,</li><li>• anal membrane</li><li>• Option B. High ARMs in females can lead to a persistent cloaca , which is a condition where the rectum, vagina, and urethra converge into a single common channel.</li><li>• Option B.</li><li>• High ARMs in females can lead to a persistent cloaca</li><li>• rectum, vagina, and urethra converge</li><li>• Option D: Anoplasty is a surgical procedure used to create an anal opening and is the appropriate treatment for imperforate anus.</li><li>• Option D:</li><li>• Anoplasty</li><li>• surgical procedure</li><li>• create an anal opening</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The incorrect statement regarding anorectal malformations in newborns is that recto-vesical fistulas are common in males. Instead, males with high ARM more commonly have recto-urethral fistulas.</li><li>➤ incorrect statement regarding anorectal malformations in newborns</li><li>➤ recto-vesical fistulas</li><li>➤ common in males.</li><li>➤ males with high ARM</li><li>➤ recto-urethral fistulas.</li><li>➤ According to Wingspread, ARMs are classified into:</li><li>➤ According to Wingspread, ARMs are classified into:</li><li>➤ Low ARMS:</li><li>➤ Low ARMS:</li><li>➤ Low ARMS:</li><li>➤ Imperforate anus Under fusion: anal membrane Anal stenosis</li><li>➤ Imperforate anus</li><li>➤ Under fusion: anal membrane</li><li>➤ Anal stenosis</li><li>➤ High ARMs:</li><li>➤ High ARMs:</li><li>➤ High ARMs:</li><li>➤ Rectal atresia with recto-urethral (bulbar) fistula (males) Rectal atresia with recto-vestibular fistula (females)</li><li>➤ Rectal atresia with recto-urethral (bulbar) fistula (males)</li><li>➤ recto-urethral (bulbar) fistula (males)</li><li>➤ Rectal atresia with recto-vestibular fistula (females)</li><li>➤ recto-vestibular fistula (females)</li><li>➤ Imperforate anus is treated by anoplasty whereas high ARMSs are treated by ano-rectoplasty.</li><li>➤ Imperforate anus is treated by anoplasty whereas high ARMSs are treated by ano-rectoplasty.</li><li>➤ In boys, a divided proximal sigmoid colostomy allows feeding . Repair of prostatic and bladder neck fistulae may be approached with a combined laparoscopic and perineal approach , whereas prostatic and bulbar urethral fistulae can both be approached in a posterior sagittal ano-rectoplasty (PSARP). The stoma is closed at a third stage .</li><li>➤ divided proximal sigmoid colostomy allows feeding</li><li>➤ Repair of prostatic</li><li>➤ bladder neck fistulae</li><li>➤ laparoscopic and perineal approach</li><li>➤ prostatic and bulbar urethral fistulae</li><li>➤ posterior sagittal ano-rectoplasty</li><li>➤ The stoma is closed at a third stage</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 289</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 289</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "What about the following about the condition shown below is incorrect?", "options": [{"label": "A", "text": "Age of presentation is at birth.", "correct": true}, {"label": "B", "text": "Interdigital pilonidal sinus is an occupational disease of hairdressers.", "correct": false}, {"label": "C", "text": "Intermittent pain, swelling and discharge at the base of the spine is often seen.", "correct": false}, {"label": "D", "text": "Hair follicles are rarely present in the walls of the sinus.", "correct": false}], "correct_answer": "A. Age of presentation is at birth.", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture6_paG6mqe.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. An interdigital pilonidal sinus can be an occupational disease in hairdressers , caused by chronic embedding of hair fragments between the fingers .</li><li>• Option B.</li><li>• An interdigital pilonidal sinus can be an occupational disease in hairdressers</li><li>• chronic embedding of hair fragments</li><li>• fingers</li><li>• Option C. Intermittent pain, swelling, and discharge at the base of the spine are characteristic symptoms of a pilonidal sinus due to infection and abscess formation.</li><li>• Option C.</li><li>• Intermittent pain, swelling, and discharge at the base of the spine</li><li>• pilonidal sinus</li><li>• infection and abscess formation.</li><li>• Option D. Hair follicles themselves are not commonly found in the walls of a pilonidal sinus . The condition is associated with ingrown hairs that have created a foreign body reaction in the subcutaneous tissue.</li><li>• Option D.</li><li>• Hair follicles themselves are not commonly found in the walls of a pilonidal sinus</li><li>• ingrown hairs</li><li>• created a foreign body reaction</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Pilonidal sinus disease typically does not present at birth ; it usually occurs after puberty and is more common in young adult males . The disease is characterized by intermittent pain, swelling, and discharge at the base of the spine and can be associated with occupational risks in hairdressers . Hair follicles are not commonly found in the walls of the sinus.</li><li>➤ Pilonidal sinus disease</li><li>➤ does not present at birth</li><li>➤ after puberty</li><li>➤ more common in young adult males</li><li>➤ disease</li><li>➤ intermittent pain, swelling, and discharge</li><li>➤ base of the spine</li><li>➤ occupational risks in hairdressers</li><li>➤ It is thought that the combination of buttock friction and shearing forces in that area allows shedding hair or broken hairs that have collected there to drill through the midline skin, or infection in relation to a hair follicle allows hair to enter the skin by the suction created by movement of the buttocks, so creating a subcutaneous, chronically infected, midline track. The condition is seen much more frequently in men than in women, usually after puberty and before the fourth decade of life. Patients complain of intermittent pain, swelling and discharge at the base of the spine . There is often a history of repeated abscesses that have burst spontaneously.</li><li>➤ It is thought that the combination of buttock friction and shearing forces in that area allows shedding hair or broken hairs that have collected there to drill through the midline skin, or infection in relation to a hair follicle allows hair to enter the skin by the suction created by movement of the buttocks, so creating a subcutaneous, chronically infected, midline track.</li><li>➤ buttock friction and shearing forces</li><li>➤ The condition is seen much more frequently in men than in women, usually after puberty and before the fourth decade of life. Patients complain of intermittent pain, swelling and discharge at the base of the spine . There is often a history of repeated abscesses that have burst spontaneously.</li><li>➤ intermittent pain, swelling and discharge at the base of the spine</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1423</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th Ed. Pg 1423</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the procedure done for the pilonidal sinus.", "options": [{"label": "A", "text": "Bascom’s procedure", "correct": true}, {"label": "B", "text": "Karydakis flap", "correct": false}, {"label": "C", "text": "Limberg flap", "correct": false}, {"label": "D", "text": "Chimeric flap", "correct": false}], "correct_answer": "A. Bascom’s procedure", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture7_fMkOYrH.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture8_0wHgEc3.jpg"], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. Karydakis flap: This technique involves asymmetrical excision of the sinus with the creation of a flap to move the natal cleft away from the midline , reducing the risk of recurrence.</li><li>• Option B. Karydakis flap:</li><li>• technique</li><li>• asymmetrical excision of the sinus</li><li>• creation of a flap to move the natal cleft away from the midline</li><li>• Option C. Limberg flap: This procedure utilizes a rhomboid-shaped flap and is also used for pilonidal sinus treatment. It transposes tissue to fill the defect created by the excision of the sinus.</li><li>• Option C. Limberg flap:</li><li>• utilizes a rhomboid-shaped flap</li><li>• used for pilonidal sinus treatment.</li><li>• Option D. Chimeric flap: A chimeric flap is not a standard procedure for pilonidal sinus and involves using tissue from more than one source area or vascular supply, typically used in more complex reconstructive surgeries.</li><li>• Option D. Chimeric flap:</li><li>• not a standard procedure for pilonidal sinus</li><li>• using tissue from more than one source area</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Bascom’s procedure is a surgical technique used for pilonidal sinus that involves lateral incision and excision of the tract , with the aim of minimizing recurrence and leaving the wound to heal secondarily.</li><li>➤ Bascom’s procedure</li><li>➤ surgical technique used for pilonidal sinus</li><li>➤ lateral incision and excision of the tract</li><li>➤ aim of minimizing recurrence</li><li>➤ leaving the wound to heal secondarily.</li><li>➤ 1A and 1B- Karydakis</li><li>➤ Karydakis</li><li>➤ 2A and 2B- Limberg flap</li><li>➤ Limberg flap</li><li>➤ Re : Bailey and Love 28 th Ed. Pg 1423-24</li><li>➤ Re : Bailey and Love 28 th Ed. Pg 1423-24</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In patients diagnosed with internal hemorrhoids, which of the following statements is incorrect?", "options": [{"label": "A", "text": "Bleeding is the earliest symptom", "correct": false}, {"label": "B", "text": "Bleeding is associated with severe pain", "correct": true}, {"label": "C", "text": "Portal pyemia is a rare complication", "correct": false}, {"label": "D", "text": "Sigmoidoscopy is preferred in the elderly as an investigation of choice", "correct": false}], "correct_answer": "B. Bleeding is associated with severe pain", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Bleeding is associated with severe pain</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Bleeding is the earliest symptom . The nature of the bleeding is characteristically separate from the motion and is seen either on the paper on wiping or as a fresh splash in the pan . The bleeding is rarely sufficient to cause anemia and other causes should be excluded.</li><li>• Option A:</li><li>• earliest symptom</li><li>• nature of the bleeding</li><li>• separate from the motion</li><li>• seen either on the paper on wiping</li><li>• fresh splash</li><li>• pan</li><li>• Investigations: Proctoscopy , although sigmoidoscopy is preferred in the elderly to rule out rectosigmoid malignancy (Option D)</li><li>• Investigations:</li><li>• Proctoscopy</li><li>• sigmoidoscopy</li><li>• elderly to rule out rectosigmoid malignancy</li><li>• (Option D)</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The bleeding associated with internal hemorrhoids is typically painless because it originates from above the dentate line , an area with a lesser density of pain-sensing nerves. Top of</li><li>➤ bleeding associated with internal hemorrhoids</li><li>➤ painless</li><li>➤ originates from above the dentate line</li><li>➤ area with a lesser density of pain-sensing nerves.</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1430</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1430</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is the most common complication following hemorrhoidectomy?", "options": [{"label": "A", "text": "Urinary retention", "correct": true}, {"label": "B", "text": "Fecal incontinence", "correct": false}, {"label": "C", "text": "Infection", "correct": false}, {"label": "D", "text": "Portal pyemia", "correct": false}], "correct_answer": "A. Urinary retention", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Urinary retention is the most common complication following hemorrhoidectomy from the given options (after reactionary hemorrhage). It is seen in up to 15-30% of the patients.</li><li>• Urinary retention</li><li>• common complication following hemorrhoidectomy</li><li>• seen in up to 15-30% of the patients.</li><li>• Other complications:</li><li>• Other complications:</li><li>• • Fecal incontinence (2%)</li><li>• • Infection (1 %)</li><li>• • Delayed hemorrhage (1%)</li><li>• • Stricture (1%)</li><li>• Patients typically recover quickly and can return to work within 1 to 2 weeks.</li><li>• Patients typically recover quickly</li><li>• return to work within 1 to 2 weeks.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Urinary retention is the most frequently reported complication following hemorrhoidectomy , occurring in up to 30% of patients . Management includes catheterization and addressing pain control to facilitate bladder function .</li><li>➤ Urinary retention</li><li>➤ most frequently reported complication</li><li>➤ hemorrhoidectomy</li><li>➤ up to 30% of patients</li><li>➤ Management</li><li>➤ catheterization</li><li>➤ addressing pain control to facilitate bladder function</li><li>➤ Complications of hemorrhoidectomy (Sabiston 21st ed Pg 1406):</li><li>➤ Complications of hemorrhoidectomy (Sabiston 21st ed Pg 1406):</li><li>➤ 1. Reactionary hemorrhage (1-2%) (Overall MC)</li><li>➤ 2. Acute urinary retention (1-15%)</li><li>➤ 3. Pelvic sepsis (Life threatening)</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1434</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th Ed. Pg 1434</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 40-year-old male presents to the clinic with complaints of recurrent perianal discharge and discomfort. Physical examination reveals an external opening of a fistulous tract located on the posterior aspect near the anus. Goodsall’s rule applies to?", "options": [{"label": "A", "text": "Classification of types of perianal abscess", "correct": false}, {"label": "B", "text": "Site of incision and drainage of perianal abscess", "correct": false}, {"label": "C", "text": "Classification of anatomical types of fistula-in-ano", "correct": false}, {"label": "D", "text": "Prediction of course of tract in fistula-in-ano", "correct": true}], "correct_answer": "D. Prediction of course of tract in fistula-in-ano", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture11_kxZhdrS.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture12_qHqtKjv.jpg"], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Classification of types of perianal abscess: Goodsall’s rule does not apply to abscess classification ; it is specific to fistulous tracts.</li><li>• Option A. Classification of types of perianal abscess:</li><li>• not apply to abscess classification</li><li>• Option B. Site of incision and drainage of perianal abscess: While important for abscess management , Goodsall’s rule is not used to determine the incision site.</li><li>• Option B. Site of incision and drainage of perianal abscess:</li><li>• important for abscess management</li><li>• Option C. Classification of anatomical types of fistula-in-ano: Anatomical classification, such as intersphincteric or trans-sphincteric types , is not determined by Goodsall’s rule. That is given by Park’s classification.</li><li>• Option C. Classification of anatomical types of fistula-in-ano:</li><li>• intersphincteric or trans-sphincteric types</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Goodsall’s rule predicts the direction and internal opening of an anal fistulous tract . It states that if the external opening is anterior to an imaginary transverse anal line within 3 cm of the anus , the internal opening is likely to be in the direct path, anteriorly . If the external opening is posterior to this line or greater than 3 cm from the anus , the tract usually curves to open in the midline posteriorly. This rule helps to guide surgical planning and can affect the surgical approach and technique used.</li><li>➤ Goodsall’s rule predicts the direction and internal opening of an anal fistulous tract</li><li>➤ external opening is anterior to an imaginary transverse anal line within 3 cm of the anus</li><li>➤ internal opening</li><li>➤ direct path, anteriorly</li><li>➤ external opening is posterior to this line or greater than 3 cm from the anus</li><li>➤ tract</li><li>➤ curves to open in the midline posteriorly.</li><li>➤ Goodsall’s rule used to indicate the likely position of the internal opening according to the position of the external opening (Predicts the direction of the fistulous tract and the internal opening)</li><li>➤ Goodsall’s rule</li><li>➤ indicate the likely position of the internal opening</li><li>➤ position of the external opening</li><li>➤ (Predicts the direction of the fistulous tract and the internal opening)</li><li>➤ According to Goodsall’s rule:</li><li>➤ According to Goodsall’s rule:</li><li>➤ External opening: Anterior within 3 cm, internal opening will also be anterior in the same line. External opening is posterior, internal opening will also be posterior but in midline (6 o clock). Anterior opening &gt; 3cm , then internal opening will be posterior (6 o clock) with a curved tract.</li><li>➤ External opening: Anterior within 3 cm, internal opening will also be anterior in the same line.</li><li>➤ External opening:</li><li>➤ External opening is posterior, internal opening will also be posterior but in midline (6 o clock).</li><li>➤ Anterior opening &gt; 3cm , then internal opening will be posterior (6 o clock) with a curved tract.</li><li>➤ Anterior opening &gt; 3cm</li><li>➤ Anatomical types of fistula-in-ano are given by Park’s classification:</li><li>➤ Park’s classification:</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1436-37.</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1436-37.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 35-year-old male with a history of chronic anal pain and recurrent perianal infections presents to the clinic. Physical examination reveals an external opening near the anal margin. A diagnosis of fistula-in-ano is considered. Which of the following types of fistula-in-ano is the least common?", "options": [{"label": "A", "text": "Extra sphincteric", "correct": true}, {"label": "B", "text": "Inter-sphincteric", "correct": false}, {"label": "C", "text": "Supra sphincteric", "correct": false}, {"label": "D", "text": "Trans sphincteric", "correct": false}], "correct_answer": "A. Extra sphincteric", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Park’s classification of fistula of ano</li><li>• Park’s classification of fistula of ano</li><li>• Low fistulae:</li><li>• Low fistulae:</li><li>• Type 1: Inter-sphincteric: 45%</li><li>• Type 2: Trans-sphincteric: 40%</li><li>• High fistulae:</li><li>• High fistulae:</li><li>• Type 3: Supra sphincteric: 10%</li><li>• Type 4: Extra sphincteric: 5%</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Extra sphincteric fistula-in-ano is the least common type , characterized by a tract that originates from the rectal wall , crosses the levator ani muscle , and is commonly associated with systemic disease or trauma.</li><li>➤ Extra sphincteric fistula-in-ano</li><li>➤ least common type</li><li>➤ tract that originates from the rectal wall</li><li>➤ crosses the levator ani muscle</li><li>➤ systemic disease or trauma.</li><li>➤ Ref : Bailey and Love, pg 1436-1437</li><li>➤ Ref : Bailey and Love, pg 1436-1437</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45 years old male presents to the clinic with a history of discharge from the anal region for the past 2 weeks. He underwent drainage of the ischiorectal abscess 2 months back. Clinical examination and imaging reveal the presence of a supra-sphincteric perianal fistula. How will you manage this patient?", "options": [{"label": "A", "text": "Seton's technique", "correct": true}, {"label": "B", "text": "NIGRO regimen", "correct": false}, {"label": "C", "text": "Delorme procedure", "correct": false}, {"label": "D", "text": "Fistulectomy", "correct": false}], "correct_answer": "A. Seton's technique", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. Chemoradiation therapy: The Nigro regimen is chemoradiation therapy , usually for anal carcinoma , and not indicated for fistula treatment.</li><li>• Option B. Chemoradiation therapy:</li><li>• Nigro regimen is chemoradiation therapy</li><li>• anal carcinoma</li><li>• Option C. Rectal prolapse repair: The Delorme procedure is a rectal prolapse repair technique and is not applicable for treating anal fistulas.</li><li>• Option C. Rectal prolapse repair:</li><li>• Delorme procedure is a rectal prolapse repair technique</li><li>• Option D. Fistula excision: Fistulectomy involves excising the fistula tract and is usually reserved for low-lying fistulas where there is less risk of compromising sphincter function.</li><li>• Option D. Fistula excision:</li><li>• Fistulectomy</li><li>• excising the fistula tract</li><li>• reserved for low-lying fistulas</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Seton's technique is the preferred method for managing high-lying anal fistulas , such as supra-sphincteric fistulas , due to its ability to promote fibrosis and maintain continence while minimizing the risk of damage to the anal sphincters.</li><li>➤ Seton's technique</li><li>➤ preferred method for managing high-lying anal fistulas</li><li>➤ supra-sphincteric fistulas</li><li>➤ ability to promote fibrosis</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1439</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1439</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is incorrect about anorectal abscess?", "options": [{"label": "A", "text": "The cryptoglandular theory states an infected inter-sphincteric gland is the starting point of abscess", "correct": false}, {"label": "B", "text": "Ischiorectal abscess is the most common type of anorectal abscess", "correct": true}, {"label": "C", "text": "Palpable, tender, erythematous perianal swelling is suggestive of abscess", "correct": false}, {"label": "D", "text": "These abscesses are drained by cruciate incision", "correct": false}], "correct_answer": "B. Ischiorectal abscess is the most common type of anorectal abscess", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Ischiorectal abscess is the most common type of anorectal abscess</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: The cryptoglandular theory of inter-sphincteric anal gland infection (Parks) holds that pus , which travels along the path of least resistance , may spread caudally to present as a perianal abscess , laterally across the external sphincter to form an ischiorectal abscess or, rarely, superiorly above the anorectal junction to form a supra levator intermuscular.</li><li>• Option A:</li><li>• cryptoglandular theory of inter-sphincteric anal gland infection</li><li>• holds that pus</li><li>• travels along the path of least resistance</li><li>• spread caudally to present as a perianal abscess</li><li>• Option C: A perianal abscess , confined by the terminal extensions of the longitudinal muscle, is usually associated with a short (2–3 day) history of increasingly severe , well-localized pain and a palpable tender lump at the anal margin. Examination reveals an indurated hot, tender perianal swelling.</li><li>• Option C:</li><li>• perianal abscess</li><li>• confined by the terminal extensions</li><li>• longitudinal muscle,</li><li>• associated with a short</li><li>• increasingly severe</li><li>• well-localized pain</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Perianal abscess (60%) is the MC type followed by ischiorectal abscess (30%). They are drained under anesthesia by giving a cruciate skin incision.</li><li>• Perianal abscess</li><li>• MC type followed by ischiorectal abscess</li><li>• drained under anesthesia</li><li>• cruciate skin incision.</li><li>• Ref : Bailey and Love 28 th Ed. Pg. 1434-35.</li><li>• Ref :</li><li>• Bailey and Love 28 th Ed. Pg. 1434-35.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In which of these hernias there is a tendency of contents to strangulate without getting obstructed?", "options": [{"label": "A", "text": "Littre’s hernia", "correct": false}, {"label": "B", "text": "Richter’s hernia", "correct": true}, {"label": "C", "text": "Sliding hernia", "correct": false}, {"label": "D", "text": "Amyand’s hernia", "correct": false}], "correct_answer": "B. Richter’s hernia", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/screenshot-2024-03-29-184843.png"], "explanation": "<p><strong>Ans. B) Richter’s hernia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Littre’s hernia - A Littre’s hernia involves the presence of a Meckel’s diverticulum in the hernia sac . While it can lead to complications, it is not specifically known for strangulation without obstruction.</li><li>• Option A. Littre’s hernia -</li><li>• presence of a Meckel’s diverticulum in the hernia sac</li><li>• Option C. Sliding hernia - A sliding hernia occurs when an organ, such as the sigmoid colon, forms part of the hernia sac walls . Though it can lead to obstruction, it is not specifically characterized by strangulation without obstruction.</li><li>• Option C. Sliding hernia -</li><li>• when an organ, such as the sigmoid colon, forms part of the hernia sac walls</li><li>• Option D. Amyand’s hernia - An Amyand’s hernia is an inguinal hernia containing the appendix . It could potentially lead to appendicitis within the hernia, but it is not particularly known for leading to strangulation without obstruction.</li><li>• Option D. Amyand’s hernia -</li><li>• inguinal hernia containing the appendix</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ A Richter’s hernia , which involves only part of the bowel wall , can lead to strangulation without necessarily causing complete bowel obstruction , representing a significant diagnostic and therapeutic challenge.</li><li>➤ Richter’s hernia</li><li>➤ part of the bowel wall</li><li>➤ lead to strangulation</li><li>➤ without necessarily causing complete bowel obstruction</li><li>➤ When tissue is trapped inside a hernia it is in a confined space. The narrow neck acts as a constriction ring impeding venous return and increasing pressure within the hernia. Resulting tension leads to pain and tenderness. If the hernia contains a bowel, then it may become ‘obstructed’ (partially or totally). If the pressure rises sufficiently, arterial blood is not able to enter the hernia and the contents become ischemic and may infarct . The hernia is then said to have ‘strangulated’ . The wall of the bowel perforates, releasing infected, toxic bowel content into the tissues and ultimately back into the peritoneal cavity . The risk of strangulation is highest in hernias that have a small neck of rigid tissue, leading first to irreducibility and on to strangulation .</li><li>➤ When tissue is trapped inside a hernia it is in a confined space. The narrow neck acts as a constriction ring impeding venous return and increasing pressure within the hernia. Resulting tension leads to pain and tenderness. If the hernia contains a bowel, then it may become ‘obstructed’ (partially or totally).</li><li>➤ If the hernia contains a bowel, then it may become ‘obstructed’</li><li>➤ If the pressure rises sufficiently, arterial blood is not able to enter the hernia and the contents become ischemic and may infarct . The hernia is then said to have ‘strangulated’ . The wall of the bowel perforates, releasing infected, toxic bowel content into the tissues and ultimately back into the peritoneal cavity . The risk of strangulation is highest in hernias that have a small neck of rigid tissue, leading first to irreducibility and on to strangulation .</li><li>➤ ischemic and may infarct</li><li>➤ ‘strangulated’</li><li>➤ . The risk of strangulation is highest in hernias that have a small neck of rigid tissue, leading first to irreducibility and on to strangulation</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1060</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1060</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A newborn male is brought to the pediatric clinic for a routine check-up. On examination, a bulge is noted in the right inguinal region, which becomes more prominent when the baby cries. The bulge reduces when the baby is calm and lying down. A diagnosis of congenital inguinal hernia is made. Which hormone has been implicated in its development according to recent studies?", "options": [{"label": "A", "text": "Collagenase", "correct": false}, {"label": "B", "text": "Thyroxine", "correct": false}, {"label": "C", "text": "Calcitonin gene-related peptide", "correct": true}, {"label": "D", "text": "Testosterone", "correct": false}], "correct_answer": "C. Calcitonin gene-related peptide", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Calcitonin gene related peptide</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Failure of normal development may lead to congenital hernias . The most common is an indirect inguinal hernia arising through failure of the processus vaginalis to close . As the testis (or round ligament) descends , it pulls a tube of peritoneum along with it . This tube should naturally fibrose and become obliterated, but, if it fails to do so, a hernia may develop. Recent studies have shown that calcitonin gene-related peptide and hepatocyte growth factor influence the closure of the processus, raising the possibility of a hormonal cause of hernia development.</li><li>• Failure of normal development may lead to congenital hernias . The most common is an indirect inguinal hernia arising through failure of the processus vaginalis to close .</li><li>• Failure of normal development</li><li>• congenital hernias</li><li>• The most common is an indirect inguinal hernia</li><li>• failure of the processus vaginalis to close</li><li>• As the testis (or round ligament) descends , it pulls a tube of peritoneum along with it . This tube should naturally fibrose and become obliterated, but, if it fails to do so, a hernia may develop.</li><li>• testis</li><li>• descends</li><li>• pulls a tube of peritoneum along with it</li><li>• Recent studies have shown that calcitonin gene-related peptide and hepatocyte growth factor influence the closure of the processus, raising the possibility of a hormonal cause of hernia development.</li><li>• calcitonin gene-related peptide and hepatocyte growth factor</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Calcitonin gene-related peptide (CGRP) has been implicated in the development of congenital inguinal hernias due to its role in influencing the closure of the processus vaginalis .</li><li>➤ Calcitonin gene-related peptide</li><li>➤ implicated in the development of congenital inguinal hernias</li><li>➤ role in influencing the closure of the processus vaginalis</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1059</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1059</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old male patient presents to the outpatient department with an inguinoscrotal swelling that increases with coughing and decreases when lying down. On examination, you note a bulge in the inguinal region that extends to the scrotum. The patient has been diagnosed with an indirect inguinal hernia. What clinical finding would you expect upon examination?", "options": [{"label": "A", "text": "Superficial ring will be felt 1.25cm above and medial to anterior superior iliac spine (ASIS)", "correct": false}, {"label": "B", "text": "Severe pain would indicate an uncomplicated hernia", "correct": false}, {"label": "C", "text": "An expansile cough impulse felt at the region of the deep inguinal ring", "correct": true}, {"label": "D", "text": "The internal (deep) ring lies 1.25cm below the midpoint of the Poupart’s ligament", "correct": false}], "correct_answer": "C. An expansile cough impulse felt at the region of the deep inguinal ring", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) An expansile cough impulse felt at the region of the deep inguinal ring</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation :</li><li>• Option A. Superficial ring lies 1.25cm above and medial to ASIS - This statement is incorrect. The superficial inguinal ring lies above and medial to the pubic tubercle , not the anterior superior iliac spine (ASIS).</li><li>• Option A. Superficial ring lies 1.25cm above and medial to ASIS</li><li>• incorrect.</li><li>• superficial inguinal ring</li><li>• above and medial to the pubic tubercle</li><li>• Option B. Severe pain indicates an uncomplicated hernia - Severe pain in the context of a hernia often suggests complications such as incarceration or strangulation , not an uncomplicated hernia. Therefore, this statement is false.</li><li>• Option B. Severe pain indicates an uncomplicated hernia</li><li>• complications such as incarceration or strangulation</li><li>• Option D. The internal abdominal ring lies 1.25cm below the midpoint of the Poupart’s ligament - This statement is incorrect. The internal (deep) inguinal ring lies approximately 1.25cm above the midpoint of the inguinal ligament.</li><li>• Option D. The internal abdominal ring lies 1.25cm below the midpoint of the Poupart’s ligament</li><li>• internal (deep) inguinal ring lies approximately 1.25cm above the midpoint</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ An indirect inguinal hernia can be diagnosed by eliciting an expansile cough impulse at the region of the deep inguinal ring during clinical examination.</li><li>➤ indirect inguinal hernia</li><li>➤ diagnosed by eliciting an expansile cough impulse</li><li>➤ deep inguinal ring</li><li>➤ For indirect hernias, the cough impulse is felt at the deep inguinal ring, whereas for direct hernias the impulse is felt at the superficial inguinal ring.</li><li>➤ For indirect hernias, the cough impulse is felt at the deep inguinal ring, whereas for direct hernias the impulse is felt at the superficial inguinal ring.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1061</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1061</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 60-year-old man presents with a painless bulge in the groin that enlarges with standing and reduces when lying down. On examination, the bulge is located medially to the inferior epigastric vessels. Which of the following structures does NOT form the boundary of the area where this patient's hernia is located, known as Hesselbach's triangle?", "options": [{"label": "A", "text": "Transversus abdominis", "correct": true}, {"label": "B", "text": "Inferior epigastric vessels", "correct": false}, {"label": "C", "text": "Ilio-pubic tract", "correct": false}, {"label": "D", "text": "Rectus abdominis muscle", "correct": false}], "correct_answer": "A. Transversus abdominis", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/hernia-10.jpg"], "explanation": "<p><strong>Ans. A) Transversus abdominis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. Inferior epigastric vessels - These vessels form the lateral border of Hesselbach’s triangle . Any hernia medial to these vessels in the groin area is likely a direct inguinal hernia.</li><li>• Option B. Inferior epigastric vessels</li><li>• vessels form the lateral border of Hesselbach’s triangle</li><li>• Option C. Iliopubic tract - The iliopubic tract (inguinal ligament) is considered to be part of the inferior border of Hesselbach's triangle.</li><li>• Option C. Iliopubic tract</li><li>• considered to be part of the inferior border</li><li>• Option D. Rectus abdominis muscle - The rectus abdominis muscle forms the medial border of Hesselbach’s triangle . A direct inguinal hernia may protrude through the triangle, medially to the border formed by this muscle.</li><li>• Option D. Rectus abdominis muscle</li><li>• forms the medial border of Hesselbach’s triangle</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The boundaries of Hesselbach's triangle are : inferior epigastric vessels laterally , the lateral edge of rectus abdominis muscle medially , and the inguinal ligament (or iliopubic tract by some descriptions) inferiorly.</li><li>➤ boundaries of Hesselbach's triangle are</li><li>➤ inferior epigastric vessels laterally</li><li>➤ lateral edge of rectus abdominis muscle medially</li><li>➤ inguinal ligament</li><li>➤ inferiorly.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1066</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1066</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 70-year-old male with no previous history of hernias presents with a bulge in the groin that is more pronounced when he stands or strains and decreases in size when he lies down. The bulge is located just medial to the pulsation of the inferior epigastric artery. Which of the following statements is true regarding his condition?", "options": [{"label": "A", "text": "Direct inguinal hernias may be congenital or acquired", "correct": false}, {"label": "B", "text": "Arises due to weakness in the abdominal wall, just lateral to the inferior epigastric vessels", "correct": false}, {"label": "C", "text": "They occur more commonly in the elderly", "correct": true}, {"label": "D", "text": "The most common complication is strangulation", "correct": false}], "correct_answer": "C. They occur more commonly in the elderly", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) They occur more commonly in the elderly</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Direct inguinal hernias may be congenital or acquired - This statement is false. Direct inguinal hernias are always acquired , resulting from a weakness in the abdominal wall.</li><li>• Option A. Direct inguinal hernias may be congenital or acquired -</li><li>• Direct inguinal hernias are always acquired</li><li>• Option B. Arises due to weakness in the abdominal wall, just lateral to the inferior epigastric vessels - This is incorrect. A direct inguinal hernia arises medially to the inferior epigastric vessels .</li><li>• Option B. Arises due to weakness in the abdominal wall, just lateral to the inferior epigastric vessels -</li><li>• direct inguinal hernia</li><li>• medially to the inferior epigastric vessels</li><li>• Option D. The most common complication is strangulation - This statement is false. Direct inguinal hernias are broad based and less prone to strangulation compared to indirect inguinal hernias.</li><li>• Option D. The most common complication is strangulation -</li><li>• Direct inguinal hernias</li><li>• broad based and less prone to strangulation</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Direct inguinal hernias are acquired and occur more often in elderly patients due to weakening of the abdominal wall medial to the inferior epigastric vessels . These hernias are less likely to strangulate due to their broad base.</li><li>➤ Direct inguinal hernias</li><li>➤ acquired</li><li>➤ occur more often in elderly patients</li><li>➤ weakening of the abdominal wall medial</li><li>➤ inferior epigastric vessels</li><li>➤ A direct medial hernia is more likely in elderly patients . It is broadly based and therefore unlikely to strangulate.</li><li>➤ A direct medial hernia is more likely in elderly patients . It is broadly based and therefore unlikely to strangulate.</li><li>➤ direct medial hernia</li><li>➤ elderly patients</li><li>➤ broadly based</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1066</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1066</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following statements about the inguinal canal is INCORRECT?", "options": [{"label": "A", "text": "The deep inguinal ring is a defect in the fascia transversalis", "correct": false}, {"label": "B", "text": "The inferior epigastric vessels lie just lateral to the deep inguinal ring", "correct": true}, {"label": "C", "text": "The superficial inguinal ring is a V shaped defect in the aponeurosis of external oblique", "correct": false}, {"label": "D", "text": "The roof of the inguinal canal is formed by the conjoint tendon", "correct": false}], "correct_answer": "B. The inferior epigastric vessels lie just lateral to the deep inguinal ring", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/02/untitled-188.jpg"], "explanation": "<p><strong>Ans. B) The inferior epigastric vessels lie just lateral to the deep inguinal ring</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. The deep inguinal ring is a defect in the fascia transversalis - This statement is correct . The deep inguinal ring is indeed an opening in the fascia transversalis, marking the entrance to the inguinal canal.</li><li>• Option A. The deep inguinal ring is a defect in the fascia transversalis -</li><li>• correct</li><li>• Option C. The superficial inguinal ring is a V-shaped defect in the aponeurosis of the external oblique - This statement is correct . The superficial inguinal ring is an opening in the external oblique aponeurosis that forms the exit of the inguinal canal.</li><li>• Option C. The superficial inguinal ring is a V-shaped defect in the aponeurosis of the external oblique -</li><li>• correct</li><li>• Option D. The roof of the inguinal canal is formed by the conjoint tendon - This statement is correct . The conjoint tendon, which is the fused tendon of the internal oblique and transversus abdominis muscles, forms the roof of the inguinal canal medially.</li><li>• Option D. The roof of the inguinal canal is formed by the conjoint tendon -</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The incorrect anatomic relations in the inguinal region are specifically, that the inferior epigastric vessels lie medial to the deep inguinal ring , not lateral.</li><li>➤ incorrect anatomic relations in the inguinal region</li><li>➤ inferior epigastric vessels lie medial to the deep inguinal ring</li><li>➤ Ref : Bailey and Love, 28 th edition Pg. 1065-66</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th edition Pg. 1065-66</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 55-year-old man presents with a bulge in the left groin that has progressively enlarged over the past year. On examination, the bulge becomes more prominent when the patient coughs and decreases in size when lying down. The patient has a history of chronic obstructive pulmonary disease (COPD). On further inspection, a part of the bowel appears to be forming a wall the hernia sac as shown. What is the most likely diagnosis?", "options": [{"label": "A", "text": "Hernia of hydrocele", "correct": false}, {"label": "B", "text": "Hydrocele of hernia", "correct": false}, {"label": "C", "text": "Pantaloon hernia", "correct": false}, {"label": "D", "text": "Sliding Hernia", "correct": true}], "correct_answer": "D. Sliding Hernia", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/13/105.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. D) Sliding hernia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A. Hernia of Hydrocele - This term does not accurately describe a type of hernia . A hydrocele which enlarges and pierces the dartos muscle is a “herniation” of a hydrocele.</li><li>• Option A. Hernia of Hydrocele -</li><li>• not accurately describe a type of hernia</li><li>• Option B. Hydrocele of Hernia - A hernial sac which accumulates peritoneal fluid within it, apart from contents, is a “hydrocele” of a hernia.</li><li>• Option B. Hydrocele of Hernia -</li><li>• hernial sac</li><li>• accumulates peritoneal fluid</li><li>• Option C. Pantaloon Hernia - This term describes a situation where both an indirect and a direct inguinal hernia are present simultaneously , creating a \"pantaloon\" shape as the hernia sacs straddle the inferior epigastric vessels. This is not what is being shown in the provided image.</li><li>• Option C. Pantaloon Hernia -</li><li>• situation where both an indirect and a direct inguinal hernia are present simultaneously</li><li>• \"pantaloon\" shape as the hernia sacs straddle</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ A sliding hernia is one in which an organ , such as the sigmoid colon or bladder , forms part of the hernia sac wall and can \"slide\" into the sac . This condition is particularly risky during surgical repair due to the potential for organ injury.</li><li>➤ sliding hernia</li><li>➤ which an organ</li><li>➤ sigmoid colon or bladder</li><li>➤ forms part of the hernia sac wall</li><li>➤ \"slide\" into the sac</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1060.</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th Ed. Pg 1060.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 30-year-old patient presents with a right groin swelling that has been increasing in size over the last six months. On examination, a reducible mass is noted, which becomes more prominent with the Valsalva manoeuvre. Considering the anatomy of the inguinal canal, which of the following structures would NOT be expected as content within the inguinal canal in this patient?", "options": [{"label": "A", "text": "Broad ligament in females", "correct": true}, {"label": "B", "text": "Vas deferens in males", "correct": false}, {"label": "C", "text": "Testicular vessels", "correct": false}, {"label": "D", "text": "Ilioinguinal nerve", "correct": false}], "correct_answer": "A. Broad ligament in females", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Broad ligament in females</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. Vas Deferens in Males - In males , the vas deferens, which transports sperm from the epididymis to the ejaculatory ducts , pass through the inguinal canal.</li><li>• Option B. Vas Deferens in Males -</li><li>• males</li><li>• vas deferens, which transports sperm from the epididymis to the ejaculatory ducts</li><li>• Option C. Testicular Vessels - The testicular artery and pampiniform plexus of veins , which supply blood to and drain blood from the testes , respectively, pass through the inguinal canal in males.</li><li>• Option C. Testicular Vessels -</li><li>• testicular artery and pampiniform plexus of veins</li><li>• supply blood to and drain blood from the testes</li><li>• Option D. Ilioinguinal Nerve - The ilioinguinal nerve traverses the inguinal canal in both males and females and innervates the skin of the upper medial thigh , as well as the root of the penis and upper part of the scrotum in males, and the mons pubis and labia majora in females.</li><li>• Option D. Ilioinguinal Nerve -</li><li>• traverses the inguinal canal in both males and females and innervates the skin of the upper medial thigh</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The broad ligament is not a content of the inguinal canal . In females , the round ligament of the uterus passes through the inguinal canal .</li><li>➤ broad ligament</li><li>➤ not a content of the inguinal canal</li><li>➤ females</li><li>➤ round ligament of the uterus passes through the inguinal canal</li><li>➤ Ref : 28 th Ed Bailey and Love, Pg. 1065-66</li><li>➤ Ref</li><li>➤ : 28 th Ed Bailey and Love, Pg. 1065-66</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the wrong statement concerning inguinal hernias:", "options": [{"label": "A", "text": "Herniotomy is the surgery of choice in congenital hydrocele", "correct": false}, {"label": "B", "text": "Lichtenstein’s mesh repair is known as herniorrhaphy", "correct": true}, {"label": "C", "text": "A patient with a single hernia has a 50% lifetime risk of developing a hernia on the other side.", "correct": false}, {"label": "D", "text": "Inguinal hernias are diagnosed mainly based on clinical finding", "correct": false}], "correct_answer": "B. Lichtenstein’s mesh repair is known as herniorrhaphy", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/hernia-12.jpg"], "explanation": "<p><strong>Ans. B) Lichtenstein’s mesh repair is known as herniorrhaphy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Herniotomy is the surgery of choice in congenital hydrocele - This statement is correct . Herniotomy involves the removal of the hernial sac and is the treatment of choice for a congenital hydrocele in children, as it typically involves the persistent patent processus vaginalis.</li><li>• Option A. Herniotomy is the surgery of choice in congenital hydrocele -</li><li>• correct</li><li>• Option C. A patient with a single hernia has a 50% lifetime risk of developing a hernia on the other side. Some surgeons have suggested that patients should be offered bilateral repair.</li><li>• Option C. A patient with a single hernia has a 50% lifetime risk of developing a hernia on the other side.</li><li>• Option D. Inguinal hernias are diagnosed mainly based on clinical findings - This statement is correct . Inguinal hernias are usually diagnosed based on history and physical examination findings, with imaging reserved for ambiguous cases.</li><li>• Option D. Inguinal hernias are diagnosed mainly based on clinical findings -</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Lichtenstein’s mesh repair is referred to as hernioplasty , where a synthetic mesh is used to reinforce the abdominal wall .</li><li>➤ Lichtenstein’s mesh repair</li><li>➤ hernioplasty</li><li>➤ synthetic mesh is used to reinforce the abdominal wall</li><li>➤ It is essential in men to examine the scrotal contents to exclude other pathologies and to check that the patient has both testes. It is also important to examine the opposite side because contralateral hernia is common. A patient with a single hernia has a 50% lifetime risk of developing a hernia on the other side. Some surgeons have suggested that patients should be offered bilateral repair, especially if laparoscopic surgery is planned, but this is not widespread practice at present.</li><li>➤ It is essential in men to examine the scrotal contents to exclude other pathologies and to check that the patient has both testes. It is also important to examine the opposite side because contralateral hernia is common. A patient with a single hernia has a 50% lifetime risk of developing a hernia on the other side. Some surgeons have suggested that patients should be offered bilateral repair, especially if laparoscopic surgery is planned, but this is not widespread practice at present.</li><li>➤ It is essential in men to examine the scrotal contents to exclude other pathologies and to check that the patient has both testes. It is also important to examine the opposite side because contralateral hernia is common. A patient with a single hernia has a 50% lifetime risk of developing a hernia on the other side. Some surgeons have suggested that patients should be offered bilateral repair, especially if laparoscopic surgery is planned, but this is not widespread practice at present.</li><li>➤ A patient with a single hernia has a 50% lifetime risk of developing a hernia on the other side.</li><li>➤ Ref : Bailey and Love 28 th ed. Pg 1067-69</li><li>➤ Ref : Bailey and Love 28 th ed. Pg 1067-69</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "As you review for your upcoming surgery examination, you come across a question on the classification of groin hernias. Which organization is recognized for proposing the most recent system of classification for groin hernias?", "options": [{"label": "A", "text": "Gilbert", "correct": false}, {"label": "B", "text": "Nyhus", "correct": false}, {"label": "C", "text": "Rives-Stoppa", "correct": false}, {"label": "D", "text": "European Hernia Society", "correct": true}], "correct_answer": "D. European Hernia Society", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) European Hernia Society</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Gilbert - Gilbert's classification is an older system that classifies inguinal hernias based on their anatomic position and the integrity of the inguinal canal floor.</li><li>• Option A. Gilbert -</li><li>• older system that classifies inguinal hernias</li><li>• Option B. Nyhus - The Nyhus classification, which is also one of the older systems , is based on the presence of a hernia sac , the condition of the internal ring, and the presence or absence of a posterior wall defect.</li><li>• Option B. Nyhus -</li><li>• older systems</li><li>• presence of a hernia sac</li><li>• Option C. Rives-Stoppa - This is not a classification system for hernias but rather a technique for ventral hernia repair using a large sublay mesh.</li><li>• Option C. Rives-Stoppa -</li><li>• classification system for hernias</li><li>• technique for ventral hernia repair</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The European Hernia Society's classification is the most recent system for classifying groin hernias , which includes primary or recurrent status , location of the hernia , and the size of the defect.</li><li>➤ European Hernia Society's</li><li>➤ most recent system for classifying groin hernias</li><li>➤ primary or recurrent status</li><li>➤ location of the hernia</li><li>➤ size of the defect.</li><li>➤ Ref : Bailey and Love 28 th ed. Pg 1067.</li><li>➤ Ref : Bailey and Love 28 th ed. Pg 1067.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which type of hernia is depicted in the following diagram?", "options": [{"label": "A", "text": "Richter's hernia", "correct": false}, {"label": "B", "text": "Pantaloon’s hernia", "correct": false}, {"label": "C", "text": "Littre's hernia", "correct": false}, {"label": "D", "text": "Maydl’s hernia", "correct": true}], "correct_answer": "D. Maydl’s hernia", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/hernia-13.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. D) Maydl’s hernia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. In Richter's hernia , a small portion of the antimesenteric wall of the intestine is trapped within the hernia . Strangulation can occur without the presence of intestinal obstruction. Clinically, it mimics gastroenteritis.</li><li>• Option A.</li><li>• In Richter's hernia</li><li>• small portion of the antimesenteric wall</li><li>• intestine is trapped within the hernia</li><li>• Option B. In Littre's hernia , Meckel's diverticulum is the content.</li><li>• Option B.</li><li>• In Littre's hernia</li><li>• Meckel's diverticulum</li><li>• Option C. In pantaloon hernia , both direct and indirect hernia occur on the same side.</li><li>• Option C.</li><li>• In pantaloon hernia</li><li>• direct and indirect hernia</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• The diagram illustrates a Maydl’s hernia , a condition where two bowel loops are within a hernial sac with the intervening segment lying within the peritoneal cavity and at risk for strangulation.</li><li>• diagram illustrates a Maydl’s hernia</li><li>• two bowel loops are within a hernial sac</li><li>• intervening segment lying within the peritoneal cavity</li><li>• Ref : Bailey and Love, 28 th Ed. Pg 1060</li><li>• Ref</li><li>• : Bailey and Love, 28 th Ed. Pg 1060</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following nerves is NOT contained within the 'triangle of pain' in laparoscopic inguinal hernia anatomy?", "options": [{"label": "A", "text": "Genital branch of genitofemoral nerve", "correct": true}, {"label": "B", "text": "Femoral branch of genitofemoral nerve", "correct": false}, {"label": "C", "text": "Femoral nerve", "correct": false}, {"label": "D", "text": "Lateral femoral cutaneous nerve of thigh", "correct": false}], "correct_answer": "A. Genital branch of genitofemoral nerve", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/02/untitled-192.jpg"], "explanation": "<p><strong>Ans. A) Genital branch of genitofemoral nerve</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. Femoral branch of genitofemoral nerve - The femoral branch of the genitofemoral nerve is indeed within the 'triangle of pain' , which is an area where nerve damage can cause chronic pain following hernia repair.</li><li>• Option B. Femoral branch of genitofemoral nerve -</li><li>• femoral branch of the genitofemoral nerve</li><li>• 'triangle of pain'</li><li>• Option C. Femoral nerve - The femoral nerve is also a content of the 'triangle of pain' and is at risk during hernia repair procedures.</li><li>• Option C. Femoral nerve -</li><li>• content of the 'triangle of pain'</li><li>• Option D. Lateral femoral cutaneous nerve of thigh - This nerve is the most commonly injured nerve during laparoscopic hernia repairs and is a part of the 'triangle of pain'.</li><li>• Option D. Lateral femoral cutaneous nerve of thigh -</li><li>• most commonly injured nerve during laparoscopic hernia</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The genital branch of the genitofemoral nerve is not contained within the 'triangle of pain' , but rather within the 'triangle of doom' , which is important for avoiding nerve injury during hernia repairs.</li><li>➤ genital branch of the genitofemoral nerve</li><li>➤ not contained within the 'triangle of pain'</li><li>➤ within the 'triangle of doom'</li><li>➤ Ref : Sabiston 21 st Ed. Pg 1117.</li><li>➤ Ref</li><li>➤ : Sabiston 21 st Ed. Pg 1117.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old man presents to the emergency department with a sudden onset of groin pain and a bulge that he cannot push back in. You suspect an incarcerated hernia. Which technique is appropriate for attempting the reduction of this hernia in the emergency setting?", "options": [{"label": "A", "text": "McVay procedure", "correct": false}, {"label": "B", "text": "Kiegel’s maneuver", "correct": false}, {"label": "C", "text": "Berger’s maneuver", "correct": false}, {"label": "D", "text": "Taxis", "correct": true}], "correct_answer": "D. Taxis", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Taxis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. McVay procedure - The McVay procedure is a surgical technique used to repair inguinal and femoral hernias , not a method for reducing a hernia.</li><li>• Option A. McVay procedure -</li><li>• surgical technique used to repair inguinal and femoral hernias</li><li>• Option B. Kiegel’s maneuver - Kiegel exercises, or pelvic floor exercises , are used to strengthen the muscles of the pelvic floor , not for the reduction of hernias.</li><li>• Option B. Kiegel’s maneuver -</li><li>• pelvic floor exercises</li><li>• used to strengthen the muscles of the pelvic floor</li><li>• Option C. Berger’s maneuver - There is no widely recognized hernia reduction technique known as Berger’s maneuver in the context of hernia management.</li><li>• Option C. Berger’s maneuver -</li><li>• no widely recognized hernia reduction technique</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Taxis is the method used for the manual reduction of an incarcerated hernia in the emergency setting .</li><li>➤ Taxis</li><li>➤ method used for the manual reduction</li><li>➤ incarcerated hernia</li><li>➤ emergency setting</li><li>➤ Ref : Bailey and Love,28 th Ed. Pg 1062</li><li>➤ Ref</li><li>➤ : Bailey and Love,28 th Ed. Pg 1062</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Double-breasting repair for inguinal hernia is described in which of the given techniques of herniorrhaphy?", "options": [{"label": "A", "text": "Desarda repair", "correct": false}, {"label": "B", "text": "Bassini repair", "correct": false}, {"label": "C", "text": "Shouldice repair", "correct": true}, {"label": "D", "text": "Lichstenstein’s Hernia repair", "correct": false}], "correct_answer": "C. Shouldice repair", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Shouldice repair</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Desarda - The Desarda repair uses a strip of the external oblique aponeurosis to reinforce the posterior wall of the inguinal canal without the use of mesh.</li><li>• Option A. Desarda -</li><li>• uses a strip of the external oblique aponeurosis</li><li>• reinforce the posterior wall</li><li>• Option B. Bassini repair - In the Bassini repair, sutures are placed between the conjoint tendon and the inguinal ligament to strengthen the posterior wall of the inguinal canal , but it does not involve a \"double breasting\" technique.</li><li>• Option B. Bassini repair -</li><li>• sutures are placed between the conjoint tendon and the inguinal ligament</li><li>• strengthen the posterior wall of the inguinal canal</li><li>• Option D. Lichtenstein’s Hernia repair - The Lichtenstein repair is a tension-free mesh repair where a synthetic mesh covers the hernia defect and is sutured to the surrounding tissue, not involving a double-breasted approach.</li><li>• Option D. Lichtenstein’s Hernia repair -</li><li>• tension-free mesh repair</li><li>• synthetic mesh covers the hernia defect</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Shouldice repair is the technique in herniorrhaphy that uses a \"double breasting\" method to reconstruct the transversalis fascia , creating a strong, four-layered posterior wall of the inguinal canal .</li><li>➤ Shouldice repair</li><li>➤ technique in herniorrhaphy that uses a \"double breasting\" method</li><li>➤ reconstruct the transversalis fascia</li><li>➤ strong, four-layered posterior wall of the inguinal canal</li><li>➤ Bassini’s repair: Sutures are placed between the conjoint tendon above and the inguinal ligament below, extending from the pubic tubercle to the deep inguinal ring. The posterior wall of the inguinal canal is thus strengthened Expert centers have reported lifetime failure rates of less than 2% after Shouldice repair but it is a technically demanding operation that, in most hands, gives results similar to those of a Bassini repair. Today, when a Bassini-type operation is done, most surgeons use a continuous, non-absorbable nylon or polypropylene suture that is darned between the conjoint tendon and inguinal ligament (Maloney)</li><li>➤ Bassini’s repair: Sutures are placed between the conjoint tendon above and the inguinal ligament below, extending from the pubic tubercle to the deep inguinal ring. The posterior wall of the inguinal canal is thus strengthened</li><li>➤ Bassini’s repair:</li><li>➤ Expert centers have reported lifetime failure rates of less than 2% after Shouldice repair but it is a technically demanding operation that, in most hands, gives results similar to those of a Bassini repair.</li><li>➤ Today, when a Bassini-type operation is done, most surgeons use a continuous, non-absorbable nylon or polypropylene suture that is darned between the conjoint tendon and inguinal ligament (Maloney)</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1068</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1068</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 3-year-old boy was brought to the clinic with a history of reducible and painless swelling in the right groin for the past 4 months. After the clinical and radiological investigations, a diagnosis of a right-sided inguinal hernia was made. The patient is posted for hernia repair surgery. Which of the following steps is not done in this patient during the repair?", "options": [{"label": "A", "text": "Opening of the hernial sac", "correct": false}, {"label": "B", "text": "Excision of the hernial sac", "correct": false}, {"label": "C", "text": "Mesh placement", "correct": true}, {"label": "D", "text": "Trans fixation of the neck", "correct": false}], "correct_answer": "C. Mesh placement", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Opening of the hernial sac - This step is performed in pediatric herniotomy to allow the contents of the hernia sac to be examined and reduced back into the abdominal cavity.</li><li>• Option A. Opening of the hernial sac -</li><li>• performed in pediatric herniotomy</li><li>• allow the contents of the hernia sac</li><li>• Option B. Excision of the hernial sac - This involves removing the patent processus vaginalis , which is the indirect sac commonly associated with congenital hernias, and is a step in the procedure.</li><li>• Option B. Excision of the hernial sac -</li><li>• removing the patent processus vaginalis</li><li>• Option D. Transfixation of the neck - This refers to suturing the neck of the hernia sac to prevent the recurrence of the hernia , and it is a part of the pediatric herniotomy.</li><li>• Option D. Transfixation of the neck -</li><li>• suturing the neck of the hernia sac</li><li>• prevent the recurrence of the hernia</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In the surgical repair of congenital inguinal hernia in children , the inguinal ring is typically not repaired and no mesh is needed for reinforcement , because the hernia is due to the presence of a patent processus vaginalis and not due to the weakening of the abdominal wall structures.</li><li>➤ surgical repair of congenital inguinal hernia in children</li><li>➤ inguinal ring</li><li>➤ not repaired and no mesh is needed for reinforcement</li><li>➤ hernia is due to the presence of a patent processus vaginalis</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1068</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th Ed. Pg 1068</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "An inguinal hernia repair in which, a 1-2 cm strip of EO aponeurosis lying over the inguinal canal is isolated from the main muscle and sutured to the conjoint tendon and inguinal ligament reinforcing the posterior abdominal wall is called?", "options": [{"label": "A", "text": "Bassini repair", "correct": false}, {"label": "B", "text": "Desarda repair", "correct": true}, {"label": "C", "text": "Shouldice repair", "correct": false}, {"label": "D", "text": "Lockwood’s repair", "correct": false}], "correct_answer": "B. Desarda repair", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Bassini repair - This traditional technique for hernia repair involves suturing the conjoint tendon to the inguinal ligament , without the use of mesh or aponeurotic extension.</li><li>• Option A. Bassini repair -</li><li>• traditional technique</li><li>• hernia repair involves suturing the conjoint tendon</li><li>• inguinal ligament</li><li>• Option C. Shouldice repair - The Shouldice repair is a tissue-based technique that includes a four-layer reinforcement of the inguinal canal but does not utilize an external oblique aponeurosis strip as in the Desarda repair.</li><li>• Option C. Shouldice repair -</li><li>• tissue-based technique that includes a four-layer reinforcement</li><li>• inguinal canal</li><li>• Option D. Lockwood’s repair - Lockwood's repair refers to a technique for treating femoral hernias , which involves lowering the inguinal ligament to cover the femoral canal but is not related to the use of an external oblique aponeurosis strip.</li><li>• Option D. Lockwood’s repair -</li><li>• technique for treating femoral hernias</li><li>• lowering the inguinal ligament to cover the femoral canal</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Desarda repair is the technique in which a strip of external oblique aponeurosis is used to reinforce the posterior wall of the inguinal canal by suturing it to the conjoint tendon and inguinal ligament.</li><li>➤ Desarda repair is the technique</li><li>➤ strip of external oblique aponeurosis is used to reinforce the posterior wall of the inguinal canal</li><li>➤ suturing it to the conjoint tendon</li><li>➤ inguinal ligament.</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg. 1068</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th Ed. Pg. 1068</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient who underwent Lichtenstein’s open mesh repair for an inguinal hernia returns to the clinic complaining of discomfort at the surgical site persisting several months postoperatively. Which is the most common complication following open mesh repair?", "options": [{"label": "A", "text": "Bleeding", "correct": false}, {"label": "B", "text": "Wound infection", "correct": false}, {"label": "C", "text": "Recurrence", "correct": false}, {"label": "D", "text": "Chronic pain", "correct": true}], "correct_answer": "D. Chronic pain", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Chronic pain</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Bleeding - Postoperative bleeding can occur but is not the most common complication following Lichtenstein’s repair.</li><li>• Option A. Bleeding -</li><li>• not the most common complication</li><li>• Option B. Wound infection - Wound infections are a risk with any surgery but are less common with mesh repairs compared to the complication under discussion.</li><li>• Option B. Wound infection -</li><li>• risk with any surgery</li><li>• less common with mesh repairs</li><li>• Option C: Recurrence - Hernia recurrence is a potential complication but has been significantly reduced with the use of the Lichtenstein technique.</li><li>• Option C: Recurrence -</li><li>• potential complication but has been significantly reduced</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Chronic pain is the most common long-term complication following Lichtenstein’s open mesh repair for inguinal hernias.</li><li>➤ Chronic pain</li><li>➤ most common long-term complication</li><li>➤ Lichtenstein’s open mesh repair</li><li>➤ inguinal hernias.</li><li>➤ Lichtenstein’s tension-free repair:</li><li>➤ Lichtenstein’s tension-free repair:</li><li>➤ Once the hernia sac has been removed and any medial defect closed, a piece of mesh measuring 8 × 15 cm is placed over the posterior wall , behind the spermatic cord, and is slit to wrap around the spermatic cord at the deep inguinal ring. Loose sutures hold the mesh to the inguinal ligament and conjoint tendon. Two major advantages are claimed:</li><li>➤ Once the hernia sac has been removed and any medial defect closed, a piece of mesh measuring 8 × 15 cm is placed over the posterior wall , behind the spermatic cord, and is slit to wrap around the spermatic cord at the deep inguinal ring. Loose sutures hold the mesh to the inguinal ligament and conjoint tendon.</li><li>➤ mesh measuring 8 × 15 cm is placed over the posterior wall</li><li>➤ Two major advantages are claimed:</li><li>➤ Two major advantages are claimed:</li><li>➤ Lower hernia recurrence rates Accelerated postoperative recovery.</li><li>➤ Lower hernia recurrence rates</li><li>➤ Accelerated postoperative recovery.</li><li>➤ Randomized trials show that hernia recurrence within the first 2 years is lower but acute pain scores are similar. Compared with an open approach, the laparoscopic approach is associated with reduced pain both immediately after surgery and up to 5 years later, a more rapid return to full activity, and a reduced incidence of wound complications such as infection, bleeding and seroma. Laparoscopic surgery is of particular benefit in bilateral hernias and patients with hernia recurrence after open surgery</li><li>➤ Randomized trials show that hernia recurrence within the first 2 years is lower but acute pain scores are similar.</li><li>➤ Compared with an open approach, the laparoscopic approach is associated with reduced pain both immediately after surgery and up to 5 years later, a more rapid return to full activity, and a reduced incidence of wound complications such as infection, bleeding and seroma.</li><li>➤ laparoscopic approach</li><li>➤ reduced incidence of wound complications such as infection, bleeding and seroma.</li><li>➤ Laparoscopic surgery is of particular benefit in bilateral hernias and patients with hernia recurrence after open surgery</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1068-69</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1068-69</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which type of hernia is not typically addressed with a laparoscopic approach for inguinal hernia repair like TEP/TAPP?", "options": [{"label": "A", "text": "Recurrent inguinal", "correct": false}, {"label": "B", "text": "Femoral", "correct": false}, {"label": "C", "text": "Sliding inguinal", "correct": false}, {"label": "D", "text": "Hernia of hydrocele", "correct": true}], "correct_answer": "D. Hernia of hydrocele", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Hernia of hydrocele</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Recurrent inguinal - Laparoscopic repair can be used for recurrent inguinal hernias , particularly if the initial repair was open, allowing the surgeon to avoid scar tissue from the previous surgery.</li><li>• Option A. Recurrent inguinal -</li><li>• Laparoscopic repair</li><li>• recurrent inguinal hernias</li><li>• Option B. Femoral - Femoral hernias can also be repaired laparoscopically . The technique allows excellent visualization of the femoral space for proper mesh placement.</li><li>• Option B. Femoral -</li><li>• Femoral hernias</li><li>• repaired laparoscopically</li><li>• Option C. Sliding inguinal - Although technically more challenging, sliding inguinal hernias , where part of the bowel or another organ is part of the hernia sac , can be repaired laparoscopically.</li><li>• Option C. Sliding inguinal -</li><li>• sliding inguinal hernias</li><li>• part of the bowel or another organ is part of the hernia sac</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Laparoscopic inguinal hernia repair is used to address direct and indirect inguinal , femoral and even obturator hernias .</li><li>➤ Laparoscopic inguinal hernia repair</li><li>➤ address direct and indirect inguinal</li><li>➤ femoral</li><li>➤ obturator hernias</li><li>➤ Two techniques are described and have been extensively studied: Totally Extraperitoneal (TEP) Transabdominal preperitoneal (TAPP) approach. In both, the aim of surgery is to reduce the hernia and hernia sac from within the abdomen and place a 10 × 15 cm mesh (or larger) in the preperitoneal plane, just deep to the abdominal wall extending medially into the retropubic space and at least 5 cm lateral to the deep inguinal ring. The mesh covers Hesselbach’s triangle, the deep inguinal ring and the femoral canal . In TEP, the surgeon develops the extraperitoneal plane just deep to the abdominal muscles, taking care not to enter the peritoneal cavity. In TAPP, the surgeon enters the peritoneal cavity first and incises the peritoneum above the hernia defect to open up the extraperitoneal space as in TEP.</li><li>➤ Two techniques are described and have been extensively studied: Totally Extraperitoneal (TEP) Transabdominal preperitoneal (TAPP) approach.</li><li>➤ Totally Extraperitoneal (TEP) Transabdominal preperitoneal (TAPP) approach.</li><li>➤ Totally Extraperitoneal (TEP)</li><li>➤ (TEP)</li><li>➤ Transabdominal preperitoneal (TAPP) approach.</li><li>➤ (TAPP)</li><li>➤ In both, the aim of surgery is to reduce the hernia and hernia sac from within the abdomen and place a 10 × 15 cm mesh (or larger) in the preperitoneal plane, just deep to the abdominal wall extending medially into the retropubic space and at least 5 cm lateral to the deep inguinal ring.</li><li>➤ The mesh covers Hesselbach’s triangle, the deep inguinal ring and the femoral canal .</li><li>➤ Hesselbach’s triangle, the deep inguinal ring and the femoral canal</li><li>➤ In TEP, the surgeon develops the extraperitoneal plane just deep to the abdominal muscles, taking care not to enter the peritoneal cavity.</li><li>➤ In TAPP, the surgeon enters the peritoneal cavity first and incises the peritoneum above the hernia defect to open up the extraperitoneal space as in TEP.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1069</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1069</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the true statement concerning femoral hernia:", "options": [{"label": "A", "text": "The hernia appears below and lateral to the pubic tubercle", "correct": true}, {"label": "B", "text": "More common in males", "correct": false}, {"label": "C", "text": "Lotheisen surgery is the low-approach surgery for femoral hernia.", "correct": false}, {"label": "D", "text": "Does not strangulate easily", "correct": false}], "correct_answer": "A. The hernia appears below and lateral to the pubic tubercle", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) The hernia appears below and lateral to the pubic tubercle</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: More common in women compared to men. The female pelvis has a different shape from the male, increasing the size of the femoral canal and the risk of hernia . In old age, the femoral defect enlarges further and femoral hernia is commonly seen in thin, elderly women.</li><li>• Option B:</li><li>• More common in women</li><li>• increasing the size of the femoral canal and the risk of hernia</li><li>• Option C: Lockwood surgery is the low approach surgery for femoral hernia.</li><li>• Option C:</li><li>• Lockwood surgery</li><li>• Transverse incision is made over the hernia. The sac of the hernia is opened and its contents reduced . The sac is also reduced and non-absorbable sutures are placed between the inguinal ligament above and the pectineal ligament overlying the pubic bone below.</li><li>• The sac of the hernia is opened and its contents reduced</li><li>• Option D: As it has a narrow neck, it strangulates early (50%).</li><li>• Option D:</li><li>• narrow neck, it strangulates early</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ A femoral hernia appears below and lateral to the pubic tubercle and is more prone to strangulation due to its narrow neck.</li><li>➤ femoral hernia</li><li>➤ below and lateral to the pubic tubercle</li><li>➤ more prone to strangulation due to its narrow neck.</li><li>➤ Ref : Bailey and Love 28 th ed., Pg. 1071-72</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th ed., Pg. 1071-72</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A medical student is presented with a patient who has a palpable mass in the epigastric region. The student is asked to identify the incorrect statement regarding the characteristics of the hernia. Which statement is incorrect?", "options": [{"label": "A", "text": "These hernias mainly contain fat, and rarely any bowel", "correct": false}, {"label": "B", "text": "Cough impulse is diagnostic of such hernias", "correct": true}, {"label": "C", "text": "Can present with pain instead of swelling", "correct": false}, {"label": "D", "text": "Surgery involves pushing back the extraperitoneal fat back into the defect", "correct": false}], "correct_answer": "B. Cough impulse is diagnostic of such hernias", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/02/untitled-193.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B) Cough impulse is diagnostic of such hernias</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. These hernias mainly contain fat, and rarely any bowel - This is generally true for epigastric hernias. They often contain preperitoneal fat and less commonly bowel.</li><li>• Option A. These hernias mainly contain fat, and rarely any bowel -</li><li>• true</li><li>• Option C. Can present with pain instead of swelling - Epigastric hernias can be painful , especially if the fatty content within them becomes trapped or \"nipped ,\" which may lead to pain indicative of early strangulation.</li><li>• Option C. Can present with pain instead of swelling -</li><li>• Epigastric hernias</li><li>• painful</li><li>• fatty content within them becomes trapped or \"nipped</li><li>• Option D. Surgery involves pushing back the extraperitoneal fat back into the defect - In surgical repair , protruding fat is indeed pushed back into the abdominal cavity, or the fat may be excised, and the defect is closed.</li><li>• Option D. Surgery involves pushing back the extraperitoneal fat back into the defect -</li><li>• surgical repair</li><li>• protruding fat</li><li>• pushed back</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The presence of a cough impulse is not a reliable diagnostic feature of epigastric hernias , as these hernias may not produce a palpable impulse due to their small size and content.</li><li>➤ presence of a cough impulse</li><li>➤ not a reliable diagnostic feature of epigastric hernias</li><li>➤ hernias may not produce a palpable impulse</li><li>➤ Very small epigastric hernias have been known to disappear spontaneously, probably because of infarction of the fat.</li><li>➤ This may be open or laparoscopic. At open surgery, a vertical or transverse incision is made over the swelling and down to the linea alba . Protruding extraperitoneal fat can simply be pushed back through the defect or excised.</li><li>➤ At open surgery, a vertical or transverse incision is made over the swelling and down to the linea alba</li><li>➤ Small defects in the linea alba may be closed with non-absorbable sutures in adults and absorbable sutures in children ; however, in larger hernias and when a peritoneal sac is present, the surgical approach is similar to that described for an umbilical mesh repair.</li><li>➤ Small defects in the linea alba</li><li>➤ closed with non-absorbable sutures in adults</li><li>➤ absorbable sutures in children</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg. 1074-75</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th Ed. Pg. 1074-75</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 35-year-old woman delivered a healthy male child 5 years back. Since then, she has a swelling in the umbilical region and has been posted for surgery for the same. Which operation will be done for this condition?", "options": [{"label": "A", "text": "Bassini repair", "correct": false}, {"label": "B", "text": "Desarda repair", "correct": false}, {"label": "C", "text": "Mayo’s operation", "correct": true}, {"label": "D", "text": "McEvedy repair", "correct": false}], "correct_answer": "C. Mayo’s operation", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Mayo’s operation</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Options A. Bassini and Option B. Desarda are surgeries used for inguinal hernias</li><li>• Options A. Bassini</li><li>• Option B. Desarda are surgeries used for inguinal hernias</li><li>• Option D. Mcevedy’s is a high approach surgery used for femoral hernias . Incision is taken on lower part of Rectus Abdominal (transversely) and pre-peritoneal plane is entered to access the hernia.</li><li>• Option D. Mcevedy’s is a high approach surgery</li><li>• femoral hernias</li><li>• Other approaches for femoral hernia include:</li><li>• Other approaches for femoral hernia include:</li><li>• Low approach of Lockwood- incision taken below inguinal ligament directly on hernia Inguinal/mid approach of Lothiessan - incision on inguinal canal</li><li>• Low approach of Lockwood- incision taken below inguinal ligament directly on hernia</li><li>• Inguinal/mid approach of Lothiessan - incision on inguinal canal</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Mayo operation , which involves overlapping folds of fascia in a \"double-breasting\" manner, is the appropriate surgical repair for a small umbilical hernia .</li><li>➤ Mayo operation</li><li>➤ overlapping folds of fascia in a \"double-breasting\"</li><li>➤ appropriate surgical repair for a small umbilical hernia</li><li>➤ Ref : bailey 28 th ed pages 1072-74</li><li>➤ Ref</li><li>➤ : bailey 28 th ed pages 1072-74</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of these are correctly matched boundaries of the femoral ring except?", "options": [{"label": "A", "text": "Superior- Inguinal ligament", "correct": false}, {"label": "B", "text": "Inferior- Pecten pubis", "correct": false}, {"label": "C", "text": "Medial- Lacunar ligament", "correct": false}, {"label": "D", "text": "Lateral- Conjoint tendon", "correct": true}], "correct_answer": "D. Lateral- Conjoint tendon", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/02/untitled-194.jpg"], "explanation": "<p><strong>Ans. D) Lateral- Conjoint tendon</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Superior - Inguinal ligament - This is correct . The inguinal ligament forms the superior border of the femoral canal.</li><li>• Option A. Superior - Inguinal ligament -</li><li>• correct</li><li>• Option B. Inferior - Pecten pubis - The pecten pubis , or pectineal line of the pubic bone , contributes to the inferior border of the femoral canal.</li><li>• Option B. Inferior - Pecten pubis -</li><li>• pecten pubis</li><li>• pectineal line of the pubic bone</li><li>• Option C. Medial - Lacunar ligament - The lacunar ligament , also known as Gimbernat's ligament , forms the medial border of the femoral canal.</li><li>• Option C. Medial - Lacunar ligament -</li><li>• lacunar ligament</li><li>• Gimbernat's ligament</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The conjoint tendon does not form the lateral border of the femoral ring ; rather, the femoral vein occupies this position.</li><li>➤ conjoint tendon does not form the lateral border of the femoral ring</li><li>➤ femoral vein occupies this position.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1071</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1071</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All are examples of ventral hernias except?", "options": [{"label": "A", "text": "Parastomal hernia", "correct": false}, {"label": "B", "text": "Femoral hernia", "correct": true}, {"label": "C", "text": "Epigastric hernia", "correct": false}, {"label": "D", "text": "Lumbar hernia", "correct": false}], "correct_answer": "B. Femoral hernia", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/30/screenshot-2024-03-30-095414.png"], "explanation": "<p><strong>Ans. B) Femoral hernia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Parastomal hernia - A parastomal hernia is a type of ventral hernia that occurs adjacent to a stoma site , such as a colostomy or ileostomy.</li><li>• Option A. Parastomal hernia -</li><li>• type of ventral hernia</li><li>• occurs adjacent to a stoma site</li><li>• Option C. Epigastric hernia - An epigastric hernia occurs between the umbilicus and the xiphoid process and is indeed a ventral hernia.</li><li>• Option C. Epigastric hernia -</li><li>• between the umbilicus and the xiphoid process</li><li>• Option D. Lumbar hernia - Although occurring in the posterior abdominal wall , lumbar hernias are sometimes categorized as ventral due to their relation to the abdominal wall musculature.</li><li>• Option D. Lumbar hernia -</li><li>• posterior abdominal wall</li><li>• lumbar hernias</li><li>• ventral</li><li>• relation to the abdominal wall musculature.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Femoral hernias are not classified as ventral hernias , as they occur through the femoral canal , which is inferior to the inguinal ligament and not part of the anterior abdominal wall.</li><li>➤ Femoral hernias</li><li>➤ not classified as ventral hernias</li><li>➤ femoral canal</li><li>➤ inferior to the inguinal ligament</li><li>➤ Ref : Bailey and Love 28th Ed. Pg 1072</li><li>➤ Ref</li><li>➤ : Bailey and Love 28th Ed. Pg 1072</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "For an intra-peritoneal repair of a ventral hernia, which mesh is typically used due to its unique two-sided design, one to promote tissue ingrowth and one to minimize adhesions to the bowel?", "options": [{"label": "A", "text": "Polypropylene", "correct": false}, {"label": "B", "text": "Dual mesh", "correct": true}, {"label": "C", "text": "Biological mesh", "correct": false}, {"label": "D", "text": "Absorbable mesh", "correct": false}], "correct_answer": "B. Dual mesh", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Dual mesh</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Polypropylene mesh - Polypropylene mesh is inert and hydrophobic and is usually used in the extraperitoneal space due to its tendency to induce adhesions when in contact with the bowel.</li><li>• Option A. Polypropylene mesh -</li><li>• inert and hydrophobic</li><li>• usually used in the extraperitoneal space</li><li>• Option C. Biological mesh - Biological meshes are made from decellularized tissue and are used to promote neovascularization and tissue integration , but they may not be the first choice for intraperitoneal placement due to variable rates of incorporation and potential for adhesion formation.</li><li>• Option C. Biological mesh -</li><li>• decellularized tissue and are used to promote neovascularization and tissue integration</li><li>• Option D. Absorbable mesh - Absorbable meshes are not typically used for permanent repair of hernias as they degrade over time and do not provide a long-term solution.</li><li>• Option D. Absorbable mesh -</li><li>• not typically used for permanent repair</li><li>• hernias as they degrade over time</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Dual (composite) mesh is specifically designed for intraperitoneal use in ventral hernia repairs , with one surface that promotes tissue ingrowth and another that minimizes the risk of adhesions to the bowel .</li><li>➤ Dual</li><li>➤ mesh</li><li>➤ intraperitoneal use in ventral hernia repairs</li><li>➤ one surface that promotes tissue ingrowth</li><li>➤ minimizes the risk of adhesions to the bowel</li><li>➤ Other meshes in hernia:</li><li>➤ 1. Synthetic mesh:</li><li>➤ 1. Synthetic mesh:</li><li>➤ Most meshes used today are synthetic polymers of polypropylene, polyester or polytetrafluoroethylene (PTFE), but there may be other chemical additives and meshes may have a composite structure such as those with anti-adhesive barriers. Meshes for hernia repair are generally non-absorbable and designed to provoke tissue ingrowth that leads to the formation of a tissue barrier. Polypropylene is an inert, hydrophobic, monofilament material so does not generate an immune response and tends to resist bacterial ingrowth . Polyester mesh is similar but hydrophilic, and is said to encourage micro-vascular ingrowth . PTFE meshes are fat sheets, quite inert and resistant to both tissue ingrowth and adhesion formation.</li><li>➤ Most meshes used today are synthetic polymers of polypropylene, polyester or polytetrafluoroethylene (PTFE), but there may be other chemical additives and meshes may have a composite structure such as those with anti-adhesive barriers.</li><li>➤ Meshes for hernia repair are generally non-absorbable and designed to provoke tissue ingrowth that leads to the formation of a tissue barrier.</li><li>➤ Polypropylene is an inert, hydrophobic, monofilament material so does not generate an immune response and tends to resist bacterial ingrowth .</li><li>➤ Polypropylene is an inert, hydrophobic, monofilament material</li><li>➤ resist bacterial ingrowth</li><li>➤ Polyester mesh is similar but hydrophilic, and is said to encourage micro-vascular ingrowth . PTFE meshes are fat sheets, quite inert and resistant to both tissue ingrowth and adhesion formation.</li><li>➤ Polyester mesh is similar but hydrophilic, and is said to encourage micro-vascular ingrowth</li><li>➤ 2. Biological mesh: They are sheets of sterilized, decellularized, connective tissue derived from a variety of sources, including human or animal dermis, bovine pericardium or porcine intestinal submucosa. They provide a ‘scaffold’ to encourage neovascular ingrowth, fibroblast infiltration and new collagen deposition.</li><li>➤ 2. Biological mesh:</li><li>➤ sheets of sterilized, decellularized, connective tissue</li><li>➤ 3. Absorbable meshes : Synthetic absorbable meshes such as those made from polyglycolic acid, collagen or polyhydroxy butyrate may be used in temporary abdominal wall closure and for short-term buttressing suture lines but are not recommended in hernia repair as they are absorbed too quickly.</li><li>➤ 3. Absorbable meshes</li><li>➤ Mesh characteristics:</li><li>➤ Mesh characteristics:</li><li>➤ Net (woven or knitted) or sheet Synthetic or biological – mainly synthetic Large pore, small pore – large pore (lightweight mesh) causes less fibrosis and less pain If for intraperitoneal use – non-adhesive surface on one side Non-absorbable or absorbable – mainly non-absorbable</li><li>➤ Net (woven or knitted) or sheet</li><li>➤ Synthetic or biological – mainly synthetic</li><li>➤ Large pore, small pore – large pore (lightweight mesh) causes less fibrosis and less pain</li><li>➤ large pore (lightweight mesh) causes less fibrosis and less pain</li><li>➤ If for intraperitoneal use – non-adhesive surface on one side</li><li>➤ Non-absorbable or absorbable – mainly non-absorbable</li><li>➤ mainly non-absorbable</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1063-64</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1063-64</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "During laparoscopic inguinal hernia repair a tacker was accidentally placed below and lateral to the iliopubic tract. Postoperatively the patient complained of pain and soreness in the thigh. This is due to the involvement of?", "options": [{"label": "A", "text": "Lateral cutaneous nerve of thigh", "correct": true}, {"label": "B", "text": "Ilioinguinal nerve", "correct": false}, {"label": "C", "text": "Femoral nerve", "correct": false}, {"label": "D", "text": "Obturator nerve", "correct": false}], "correct_answer": "A. Lateral cutaneous nerve of thigh", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Lateral cutaneous nerve of thigh</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. Ilioinguinal nerve - The ilioinguinal nerve runs along the inguinal canal and provides sensation to the groin area . Injury to this nerve can cause pain in the groin rather than the lateral thigh.</li><li>• Option B. Ilioinguinal nerve -</li><li>• runs along the inguinal canal</li><li>• provides sensation to the groin area</li><li>• Option C. Femoral nerve - The femoral nerve lies within the femoral triangle of the upper thigh and provides motor and sensory function to the anterior thigh . It is less likely to be injured during laparoscopic hernia repair unless there is aberrant dissection.</li><li>• Option C. Femoral nerve -</li><li>• lies within the femoral triangle of the upper thigh</li><li>• provides motor and sensory function</li><li>• anterior thigh</li><li>• Option D. Obturator nerve - The obturator nerve innervates the medial thigh and is typically not in the immediate area of laparoscopic inguinal hernia repair.</li><li>• Option D. Obturator nerve -</li><li>• innervates the medial thigh</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The lateral cutaneous nerve of the thigh is the nerve most likely to be involved in postoperative pain in the lateral thigh following laparoscopic inguinal hernia repair , particularly if a tacker is placed below and lateral to the iliopubic tract.</li><li>➤ lateral cutaneous nerve</li><li>➤ thigh is the nerve most likely to be involved in postoperative pain</li><li>➤ lateral thigh</li><li>➤ laparoscopic inguinal hernia repair</li><li>➤ Ref : Online article: http://dx.doi.org/10.20517/2574-1225.2021.65</li><li>➤ Ref</li><li>➤ : Online article: http://dx.doi.org/10.20517/2574-1225.2021.65</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In a clinical scenario where a patient is undergoing a ventral hernia repair, the surgeon places a mesh in a position as depicted in the provided image. Which term best describes the placement of this mesh?", "options": [{"label": "A", "text": "Onlay", "correct": false}, {"label": "B", "text": "Inlay", "correct": false}, {"label": "C", "text": "Sublay", "correct": true}, {"label": "D", "text": "IPOM", "correct": false}], "correct_answer": "C. Sublay", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/hernia-14.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/hernia-15.jpg"], "explanation": "<p><strong>Ans. C) Sublay</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Onlay - An onlay mesh placement refers to the positioning of the mesh on top of the anterior rectus sheath , within the subcutaneous tissue.</li><li>• Option A. Onlay -</li><li>• onlay mesh placement</li><li>• positioning of the mesh on top</li><li>• anterior rectus sheath</li><li>• Option B. Inlay - Inlay mesh placement situates the mesh within the defect itself . However, this method is not typically recommended due to its similarity to suture repair.</li><li>• Option B. Inlay -</li><li>• placement situates the mesh within the defect itself</li><li>• Option D. IPOM (Intraperitoneal Onlay Mesh) - IPOM refers to the placement of the mesh within the peritoneal cavity against the abdominal wall.</li><li>• Option D. IPOM (Intraperitoneal Onlay Mesh) -</li><li>• placement of the mesh</li><li>• peritoneal cavity</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Sublay mesh placement is the preferred method for ventral hernia repair due to the mechanical advantage it provides, positioning the mesh immediately deep to the abdominal wall muscle layers but above the peritoneum.</li><li>➤ Sublay mesh placement</li><li>➤ preferred method for ventral hernia repair</li><li>➤ mechanical advantage</li><li>➤ positioning the mesh</li><li>➤ deep to the abdominal wall muscle layers</li><li>➤ peritoneum.</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 1064-65.</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 1064-65.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "“They arise through a defect in the aponeurosis of transversus abdominis and may advance through the internal oblique to spread out deep to the external oblique aponeurosis.” Which hernia is being described here?", "options": [{"label": "A", "text": "Richter’s hernia", "correct": false}, {"label": "B", "text": "Femoral hernia", "correct": false}, {"label": "C", "text": "Spigelian hernia", "correct": true}, {"label": "D", "text": "Littre’s hernia", "correct": false}], "correct_answer": "C. Spigelian hernia", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Spigelian hernia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Richter’s hernia - Richter's hernia involves the entrapment of only part of the circumference of the bowel wall , typically through the femoral canal or a defect in the abdominal wall, not specifically through the transversus abdominis aponeurosis.</li><li>• Option A. Richter’s hernia -</li><li>• entrapment of only part of the circumference of the bowel wall</li><li>• Option B. Femoral hernia - Femoral hernias protrude through the femoral ring , which is below the inguinal ligament, not through the transversus abdominis aponeurosis.</li><li>• Option B. Femoral hernia -</li><li>• protrude through the femoral ring</li><li>• Option D. Littre’s hernia - A Littre's hernia involves a Meckel's diverticulum as the hernia content , not specifically related to the transversus abdominis aponeurosis.</li><li>• Option D. Littre’s hernia -</li><li>• Meckel's diverticulum as the hernia content</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Spigelian hernia is the type that arises through a defect in the aponeurosis of the transversus abdominis muscle , often occurring below the level of the umbilicus near the lateral edge of the rectus sheath .</li><li>➤ Spigelian hernia</li><li>➤ type that arises through a defect in the aponeurosis</li><li>➤ transversus abdominis muscle</li><li>➤ occurring below the level of the umbilicus</li><li>➤ lateral edge of the rectus sheath</li><li>➤ Ref : Pg 1075, Bailey and Love 28 th ed</li><li>➤ Ref</li><li>➤ : Pg 1075, Bailey and Love 28 th ed</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In the European Hernia Society (EHS) classification, ventral hernias are categorized based on their location and size. A medical student is asked to identify a hernia classified as M3. What does this classification represent?", "options": [{"label": "A", "text": "Epigastric", "correct": false}, {"label": "B", "text": "Paraumbilical", "correct": true}, {"label": "C", "text": "Suprapubic", "correct": false}, {"label": "D", "text": "Infra-umbilical", "correct": false}], "correct_answer": "B. Paraumbilical", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/untitled-197.jpg"], "explanation": "<p><strong>Ans. B) Paraumbilical</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Epigastric hernia - Epigastric hernias occur in the epigastric region , which is above the umbilicus up to the xiphoid process . This is labelled as M2 .</li><li>• Option A. Epigastric hernia -</li><li>• epigastric region</li><li>• umbilicus up to the xiphoid process</li><li>• M2</li><li>• Option C. Suprapubic hernia - Suprapubic hernias occur just above the pubic bone and are classified as M5 .</li><li>• Option C. Suprapubic hernia -</li><li>• above the pubic bone</li><li>• M5</li><li>• Option D. Infra-umbilical hernia - Infra-umbilical hernias occur below the umbilicus and could be classified as \"M4\" in the EHS classification.</li><li>• Option D. Infra-umbilical hernia -</li><li>• below the umbilicus</li><li>• \"M4\"</li><li>• EHS classification.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The EHS classification M3 refers to a paraumbilical hernia .</li><li>➤ EHS classification M3 refers to a paraumbilical hernia</li><li>➤ Ref : Online article: DOI:10.1007/s10029-009-0518-x</li><li>➤ Ref</li><li>➤ : Online article: DOI:10.1007/s10029-009-0518-x</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 30-year-old male has intermittent severe epigastric pain for 3 months. Physical examination and ultrasound are normal, and pain is unresponsive to proton pump inhibitors. A contrast-enhanced CT scan reveals findings suggestive of a hernia. What is the next best step in management?", "options": [{"label": "A", "text": "Re-assurance", "correct": false}, {"label": "B", "text": "Upper GI scopy", "correct": false}, {"label": "C", "text": "Surgical exploration", "correct": true}, {"label": "D", "text": "Tricyclic antidepressants", "correct": false}], "correct_answer": "C. Surgical exploration", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/untitled-198.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Surgical exploration</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Re-assurance - While reassurance is an important aspect of patient care, it is not the next step in managing a symptomatic epigastric hernia that is causing severe pain.</li><li>• Option A. Re-assurance -</li><li>• not the next step in managing a symptomatic epigastric hernia</li><li>• Option B. Upper GI scopy - An upper gastrointestinal endoscopy may be helpful in evaluating other causes of epigastric pain but would not be the next step if the CT scan has already identified an epigastric hernia as the source of symptoms.</li><li>• Option B. Upper GI scopy -</li><li>• helpful in evaluating other causes of epigastric pain</li><li>• Option D. Tricyclic antidepressants - While tricyclic antidepressants are used for chronic pain syndromes , they would not be the next step in the presence of an anatomical lesion such as an epigastric hernia that is likely causing the pain.</li><li>• Option D. Tricyclic antidepressants -</li><li>• used for chronic pain syndromes</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Surgical exploration is the appropriate next step for a patient with a symptomatic epigastric hernia not relieved by medical therapy and confirmed by imaging , as it may require repair to alleviate symptoms and prevent complications.</li><li>➤ Surgical exploration</li><li>➤ symptomatic epigastric hernia</li><li>➤ medical therapy</li><li>➤ confirmed by imaging</li><li>➤ Small to moderate-sized hernias without a peritoneal sac are not inherently dangerous and surgery should be offered only if the hernia is sufficiently symptomatic. Hernias containing bowel should always be repaired .</li><li>➤ Small to moderate-sized hernias without a peritoneal sac are not inherently dangerous and surgery should be offered only if the hernia is sufficiently symptomatic.</li><li>➤ Small to moderate-sized hernias</li><li>➤ peritoneal sac</li><li>➤ dangerous</li><li>➤ Hernias containing bowel should always be repaired .</li><li>➤ Hernias</li><li>➤ bowel should always be repaired</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1074-75</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1074-75</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which location is most frequently involved in intra-abdominal abscess formation?", "options": [{"label": "A", "text": "Right subhepatic space", "correct": false}, {"label": "B", "text": "Right subphrenic space", "correct": false}, {"label": "C", "text": "Left paracolic space", "correct": false}, {"label": "D", "text": "Pelvis", "correct": true}], "correct_answer": "D. Pelvis", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Pelvis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Right subhepatic space - While abscesses can form here, especially following biliary tract surgery or with penetrating liver injuries , it is not the most common site.</li><li>• Option A. Right subhepatic space</li><li>• abscesses can form</li><li>• biliary tract surgery</li><li>• penetrating liver injuries</li><li>• Option B. Right subphrenic space - This space is also a common site for abscesses , particularly following upper abdominal surgery , but not the most common overall.</li><li>• Option B. Right subphrenic space</li><li>• space is also a common site for abscesses</li><li>• upper abdominal surgery</li><li>• Option C. Left paracolic space - Abscesses in this location may occur due to diverticulitis or other colonic pathologies , but this is not the most frequent site.</li><li>• Option C. Left paracolic space</li><li>• Abscesses</li><li>• location</li><li>• diverticulitis or other colonic pathologies</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The pelvis is the most common site for intra-abdominal abscess formation , partly due to the propensity for materials to collect in the lowest part of the abdominal cavity and also due to infectious processes in structures like the appendix and the Fallopian tubes .</li><li>➤ pelvis is the most common site for intra-abdominal abscess formation</li><li>➤ propensity for materials to collect</li><li>➤ lowest part of the abdominal cavity</li><li>➤ infectious processes</li><li>➤ appendix and the Fallopian tubes</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1095.</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1095.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the incorrect statement concerning a desmoid tumor?", "options": [{"label": "A", "text": "More common in women", "correct": false}, {"label": "B", "text": "Can occur in familial adenomatous polyposis", "correct": false}, {"label": "C", "text": "Local excision with a margin is the best treatment choice", "correct": false}, {"label": "D", "text": "It is capsulated", "correct": true}], "correct_answer": "D. It is capsulated", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) It is capsulated</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. More common in women - This is correct . Desmoid tumors, also known as aggressive fibromatosis, are more common in women.</li><li>• Option A. More common in women -</li><li>• correct</li><li>• Option B. Can occur in familial adenomatous polyposis - Desmoid tumors are indeed associated with familial adenomatous polyposis (FAP), and their occurrence is one of the extracolonic manifestations of this syndrome.</li><li>• Option B. Can occur in familial adenomatous polyposis -</li><li>• Desmoid tumors</li><li>• familial adenomatous polyposis</li><li>• Option C. Local excision with a margin is the best treatment choice - Wide local excision with a margin is considered the best treatment for desmoid tumors to reduce the risk of local recurrence .</li><li>• Option C. Local excision with a margin is the best treatment choice -</li><li>• Wide local excision</li><li>• margin</li><li>• best treatment for desmoid tumors</li><li>• reduce the risk of local recurrence</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Desmoid tumors are not encapsulated , which is important for surgical planning , as these tumors require wide local excision due to their invasive nature and high recurrence rate .</li><li>➤ Desmoid tumors</li><li>➤ not encapsulated</li><li>➤ surgical planning</li><li>➤ tumors</li><li>➤ wide local excision</li><li>➤ invasive nature</li><li>➤ high recurrence rate</li><li>➤ Ref : Bailey and Love, 28 th ed. Pg 1082</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th ed. Pg 1082</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}]; if (!Array.isArray(questions) || questions.length === 0) { throw new Error("Questions data is empty or invalid"); } debugLog(`Successfully parsed ${questions.length} questions`); } catch (e) { console.error("Failed to parse questions_json:", e); document.getElementById('error-message').innerHTML = "Error loading quiz data. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('start-test').disabled = true; // Fallback to sample questions for testing questions = [ { text: "What is 2 + 2?", options: [ { label: "A", text: "3", correct: false }, { label: "B", text: "4", correct: true }, { label: "C", text: "5", correct: false }, { label: "D", text: "6", correct: false } ], correct_answer: "B. 4", question_images: [], explanation_images: [], explanation: "<p>2 + 2 = 4</p><p>@dams_new_robot</p>", bot: "@dams_new_robot", audio: "", video: "" } ]; debugLog("Loaded fallback questions"); } // Quiz state let currentQuestion = 0; let answers = new Array(questions.length).fill(null); let markedForReview = new Array(questions.length).fill(false); let timeRemaining = 252 * 60; // Duration in seconds let timerInterval = null; const quizId = `{title.replace(/\s+/g, '_').toLowerCase()}`; // Unique ID for local storage // Load saved progress function loadProgress() { try { debugLog("Loading progress from localStorage"); const saved = localStorage.getItem(`quiz_${quizId}`); if (saved) { const { savedAnswers, savedMarked, savedTime } = JSON.parse(saved); answers = savedAnswers || answers; markedForReview = savedMarked || markedForReview; timeRemaining = savedTime !== undefined ? savedTime : timeRemaining; debugLog("Progress loaded successfully"); } else { debugLog("No saved progress found"); } } catch (e) { console.error("Error loading progress:", e); debugLog("Failed to load progress: " + e.message); } } // Save progress function saveProgress() { try { debugLog("Saving progress to localStorage"); localStorage.setItem(`quiz_${quizId}`, JSON.stringify({ savedAnswers: answers, savedMarked: markedForReview, savedTime: timeRemaining })); debugLog("Progress saved successfully"); } catch (e) { console.error("Error saving progress:", e); debugLog("Failed to save progress: " + e.message); } } // Initialize quiz function initQuiz() { try { debugLog("Initializing quiz"); loadProgress(); const startButton = document.getElementById('start-test'); if (!startButton) { throw new Error("Start test button not found"); } startButton.addEventListener('click', startQuiz); debugLog("Start test button listener attached"); document.getElementById('previous-btn').addEventListener('click', showPreviousQuestion); document.getElementById('next-btn').addEventListener('click', showNextQuestion); document.getElementById('mark-review').addEventListener('click', toggleMarkForReview); document.getElementById('nav-toggle').addEventListener('click', toggleNavPanel); document.getElementById('submit-test').addEventListener('click', showSubmitModal); document.getElementById('continue-test').addEventListener('click', closeExitModal); document.getElementById('exit-test').addEventListener('click', () => { debugLog("Exiting test"); localStorage.removeItem(`quiz_${quizId}`); window.location.reload(); }); document.getElementById('cancel-submit').addEventListener('click', closeSubmitModal); document.getElementById('confirm-submit').addEventListener('click', submitTest); document.getElementById('take-again').addEventListener('click', () => { debugLog("Restarting test"); localStorage.removeItem(`quiz_${quizId}`); window.location.reload(); }); document.getElementById('review-test').addEventListener('click', () => showResults(currentResultQuestion)); document.getElementById('close-nav').addEventListener('click', toggleNavPanel); document.getElementById('theme-toggle').addEventListener('click', toggleTheme); document.getElementById('nav-filter').addEventListener('change', updateNavPanel); document.getElementById('prev-result').addEventListener('click', showPreviousResult); document.getElementById('next-result').addEventListener('click', showNextResult); document.getElementById('results-nav-toggle').addEventListener('click', toggleResultsNavPanel); document.getElementById('close-results-nav').addEventListener('click', toggleResultsNavPanel); document.getElementById('results-nav-filter').addEventListener('change', updateResultsNavPanel); debugLog("Quiz initialized successfully"); } catch (e) { console.error("Failed to initialize quiz:", e); debugLog("Failed to initialize quiz: " + e.message); document.getElementById('error-message').innerHTML = "Error initializing quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('start-test').disabled = true; } } // Start quiz function startQuiz() { try { debugLog("Starting quiz"); document.getElementById('instructions').classList.add('hidden'); document.getElementById('quiz').classList.remove('hidden'); showQuestion(currentQuestion); startTimer(); updateNavPanel(); debugLog("Quiz started successfully"); } catch (e) { console.error("Error starting quiz:", e); debugLog("Failed to start quiz: " + e.message); document.getElementById('error-message').innerHTML = "Error starting quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('quiz').classList.add('hidden'); document.getElementById('instructions').classList.remove('hidden'); } } // Show question function showQuestion(index) { try { debugLog(`Showing question ${index + 1}`); currentQuestion = index; const q = questions[index]; if (!q) { throw new Error(`Question ${index} is undefined`); } document.getElementById('question-number').innerHTML = `Question <span>${index + 1}</span> of ${questions.length}`; document.getElementById('question-text').innerHTML = q.text || "No question text available"; const imagesDiv = document.getElementById('question-images'); imagesDiv.innerHTML = q.question_images && q.question_images.length > 0 ? q.question_images.map(url => `<img src="${url}" alt="Question Image" class="max-w-full h-auto rounded-lg">`).join('') : ''; const optionsDiv = document.getElementById('options'); optionsDiv.innerHTML = q.options && q.options.length > 0 ? q.options.map(opt => ` <button class="option-btn w-full text-left p-3 border rounded-lg ${answers[index] === opt.label ? 'selected' : ''}" onclick="selectOption(${index}, '${opt.label}')" aria-label="Option ${opt.label}: ${opt.text}"> ${opt.label}. ${opt.text} </button> `).join('') : '<p class="text-red-500">No options available</p>'; document.getElementById('previous-btn').disabled = index === 0; document.getElementById('next-btn').disabled = index === questions.length - 1; document.getElementById('mark-review').classList.toggle('marked', markedForReview[index]); updateProgressBar(); saveProgress(); window.scrollTo({ top: 0, behavior: 'smooth' }); debugLog(`Question ${index + 1} displayed successfully`); } catch (e) { console.error("Error displaying question:", e); debugLog("Failed to display question: " + e.message); } } // Select option function selectOption(index, label) { try { debugLog(`Selecting option ${label} for question ${index + 1}`); answers[index] = label; const optionsDiv = document.getElementById('options'); const optionButtons = optionsDiv.querySelectorAll('.option-btn'); optionButtons.forEach(btn => { const btnLabel = btn.textContent.trim().split('.')[0]; btn.classList.toggle('selected', btnLabel === label); }); updateNavPanel(); saveProgress(); debugLog(`Option ${label} selected for question ${index + 1}`); } catch (e) { console.error("Error selecting option:", e); debugLog("Failed to select option: " + e.message); } } // Toggle mark for review function toggleMarkForReview() { try { debugLog(`Toggling mark for review on question ${currentQuestion + 1}`); markedForReview[currentQuestion] = !markedForReview[currentQuestion]; document.getElementById('mark-review').classList.toggle('marked', markedForReview[currentQuestion]); updateNavPanel(); saveProgress(); debugLog(`Mark for review toggled for question ${currentQuestion + 1}`); } catch (e) { console.error("Error marking for review:", e); debugLog("Failed to mark for review: " + e.message); } } // Navigate to previous question function showPreviousQuestion() { try { debugLog(`Navigating to previous question from ${currentQuestion + 1}`); if (currentQuestion > 0) { currentQuestion--; showQuestion(currentQuestion); } } catch (e) { console.error("Error navigating to previous question:", e); debugLog("Failed to navigate to previous question: " + e.message); } } // Navigate to next question function showNextQuestion() { try { debugLog(`Navigating to next question from ${currentQuestion + 1}`); if (currentQuestion < questions.length - 1) { currentQuestion++; showQuestion(currentQuestion); } } catch (e) { console.error("Error navigating to next question:", e); debugLog("Failed to navigate to next question: " + e.message); } } // Handle question navigation click function handleQuestionNavClick(index) { try { debugLog(`Navigating to question ${index + 1} via nav panel`); showQuestion(index); toggleNavPanel(); } catch (e) { console.error("Error handling navigation click:", e); debugLog("Failed to navigate via nav panel: " + e.message); } } // Start timer function startTimer() { try { debugLog("Starting timer"); timerInterval = setInterval(() => { if (timeRemaining <= 0) { debugLog("Timer expired, submitting test"); clearInterval(timerInterval); submitTest(); } else { timeRemaining--; const minutes = Math.floor(timeRemaining / 60); const seconds = timeRemaining % 60; document.getElementById('timer').innerHTML = `Time Remaining: <span>${minutes.toString().padStart(2, '0')}:${seconds.toString().padStart(2, '0')}</span>`; saveProgress(); } }, 1000); debugLog("Timer started successfully"); } catch (e) { console.error("Error starting timer:", e); debugLog("Failed to start timer: " + e.message); } } // Update progress bar function updateProgressBar() { try { debugLog("Updating progress bar"); const progress = ((currentQuestion + 1) / questions.length) * 100; document.getElementById('progress-bar').style.width = `${progress}%`; debugLog("Progress bar updated"); } catch (e) { console.error("Error updating progress bar:", e); debugLog("Failed to update progress bar: " + e.message); } } // Update quiz navigation panel function updateNavPanel() { try { debugLog("Updating quiz navigation panel"); const filter = document.getElementById('nav-filter').value; const navGrid = document.getElementById('nav-grid'); navGrid.innerHTML = questions.map((_, i) => { if (filter === 'answered' && !answers[i]) return ''; if (filter === 'unanswered' && answers[i]) return ''; if (filter === 'marked' && !markedForReview[i]) return ''; return ` <button class="question-nav-btn ${answers[i] ? 'answered' : 'unanswered'} ${markedForReview[i] ? 'marked-nav' : ''}" onclick="handleQuestionNavClick(${i})" aria-label="Go to Question ${i + 1}"> ${i + 1} </button> `; }).join(''); debugLog("Quiz navigation panel updated"); } catch (e) { console.error("Error updating quiz navigation panel:", e); debugLog("Failed to update quiz navigation panel: " + e.message); } } // Update results navigation panel function updateResultsNavPanel() { try { debugLog("Updating results navigation panel"); const filter = document.getElementById('results-nav-filter').value; const navGrid = document.getElementById('results-nav-grid'); navGrid.innerHTML = questions.map((_, i) => { if (filter === 'answered' && !answers[i]) return ''; if (filter === 'unanswered' && answers[i]) return ''; if (filter === 'marked' && !markedForReview[i]) return ''; return ` <button class="result-nav-btn-grid ${answers[i] ? 'answered' : 'unanswered'} ${markedForReview[i] ? 'marked-nav' : ''}" onclick="handleResultNavClick(${i})" aria-label="Go to Result for Question ${i + 1}"> ${i + 1} </button> `; }).join(''); debugLog("Results navigation panel updated"); } catch (e) { console.error("Error updating results navigation panel:", e); debugLog("Failed to update results navigation panel: " + e.message); } } // Toggle quiz navigation panel function toggleNavPanel() { try { debugLog("Toggling quiz navigation panel"); const navPanel = document.getElementById('nav-panel'); navPanel.classList.toggle('hidden'); debugLog("Quiz navigation panel toggled"); } catch (e) { console.error("Error toggling quiz navigation panel:", e); debugLog("Failed to toggle quiz navigation panel: " + e.message); } } // Toggle results navigation panel function toggleResultsNavPanel() { try { debugLog("Toggling results navigation panel"); const resultsNavPanel = document.getElementById('results-nav-panel'); resultsNavPanel.classList.toggle('hidden'); if (!resultsNavPanel.classList.contains('hidden')) { updateResultsNavPanel(); } debugLog("Results navigation panel toggled"); } catch (e) { console.error("Error toggling results navigation panel:", e); debugLog("Failed to toggle results navigation panel: " + e.message); } } // Handle result navigation click function handleResultNavClick(index) { try { debugLog(`Navigating to result for question ${index + 1} via nav panel`); showResults(index); toggleResultsNavPanel(); } catch (e) { console.error("Error handling result navigation click:", e); debugLog("Failed to navigate to result: " + e.message); } } // Show submit modal function showSubmitModal() { try { debugLog("Showing submit modal"); const attempted = answers.filter(a => a !== null).length; document.getElementById('attempted-count').textContent = attempted; document.getElementById('unattempted-count').textContent = questions.length - attempted; document.getElementById('submit-modal').classList.remove('hidden'); debugLog("Submit modal displayed"); } catch (e) { console.error("Error showing submit modal:", e); debugLog("Failed to show submit modal: " + e.message); } } // Close submit modal function closeSubmitModal() { try { debugLog("Closing submit modal"); document.getElementById('submit-modal').classList.add('hidden'); debugLog("Submit modal closed"); } catch (e) { console.error("Error closing submit modal:", e); debugLog("Failed to close submit modal: " + e.message); } } // Close exit modal function closeExitModal() { try { debugLog("Closing exit modal"); document.getElementById('exit-modal').classList.add('hidden'); debugLog("Exit modal closed"); } catch (e) { console.error("Error closing exit modal:", e); debugLog("Failed to close exit modal: " + e.message); } } // Submit test function submitTest() { try { debugLog("Submitting test"); clearInterval(timerInterval); document.getElementById('quiz').classList.add('hidden'); document.getElementById('submit-modal').classList.add('hidden'); document.getElementById('results').classList.remove('hidden'); showResults(0); // Start with first question // Trigger confetti animation confetti({ particleCount: 100, spread: 70, origin: { y: 0.6 } }); localStorage.removeItem(`quiz_${quizId}`); debugLog("Test submitted successfully"); } catch (e) { console.error("Error submitting test:", e); debugLog("Failed to submit test: " + e.message); } } // Show result for a single question function showResults(index) { try { debugLog(`Showing result for question ${index + 1}`); currentResultQuestion = index; let correct = 0, wrong = 0, unanswered = 0, marked = 0; answers.forEach((answer, i) => { const isCorrect = answer && questions[i].options.find(opt => opt.label === answer)?.correct; if (answer === null) unanswered++; else if (isCorrect) correct++; else wrong++; if (markedForReview[i]) marked++; }); const q = questions[index]; if (!q) { throw new Error(`Question ${index} is undefined`); } const userAnswer = answers[index]; const isCorrect = userAnswer && q.options.find(opt => opt.label === userAnswer)?.correct; const resultsContent = document.getElementById('results-content'); resultsContent.innerHTML = ` <div class="border p-4 rounded-lg ${isCorrect ? 'bg-green-50' : userAnswer ? 'bg-red-50' : 'bg-gray-50'}"> <p class="font-semibold">Question ${index + 1}: ${q.text || 'No question text'}</p> ${q.question_images && q.question_images.length > 0 ? q.question_images.map(url => `<img src="${url}" alt="Question Image" class="max-w-full h-auto rounded-lg my-2">`).join('') : ''} <p><strong>Your Answer:</strong> ${userAnswer ? `${userAnswer}. ${q.options.find(opt => opt.label === userAnswer)?.text || 'Invalid option'}` : 'Unanswered'}</p> <p><strong>Correct Answer:</strong> ${q.correct_answer || 'Unknown'}</p> <div class="mt-2">${q.explanation || 'No explanation available'}</div> ${q.explanation_images && q.explanation_images.length > 0 ? q.explanation_images.map(url => `<img src="${url}" alt="Explanation Image" class="max-w-full h-auto rounded-lg my-2">`).join('') : ''} ${q.video ? ` <button class="play-video bg-blue-500 text-white px-4 py-2 rounded-lg mt-2" onclick="loadVideo(this, '${q.video}', 'video-${index}')" aria-label="Play explanation video for Question ${index + 1}"> Play Video Explanation </button> <div id="video-${index}" class="video-container mt-2"></div> ` : '<p class="text-gray-500 mt-2">No video available</p>'} ${q.audio ? ` <button class="play-audio bg-blue-500 text-white px-4 py-2 rounded-lg mt-2" onclick="loadAudio(this, '${q.audio}', 'audio-${index}')" aria-label="Play audio explanation for Question ${index + 1}"> Play Audio Explanation </button> <div id="audio-${index}" class="audio-container mt-2"></div> ` : ''} </div> `; document.getElementById('correct-count').textContent = correct; document.getElementById('wrong-count').textContent = wrong; document.getElementById('unanswered-count').textContent = unanswered; document.getElementById('marked-count').textContent = marked; document.getElementById('result-question-number').innerHTML = `Question <span>${index + 1}</span> of ${questions.length}`; document.getElementById('prev-result').disabled = index === 0; document.getElementById('next-result').disabled = index === questions.length - 1; updateResultsNavPanel(); window.scrollTo({ top: 0, behavior: 'smooth' }); debugLog(`Result for question ${index + 1} displayed successfully`); } catch (e) { console.error("Error displaying result:", e); debugLog("Failed to display result: " + e.message); } } // Navigate to previous result function showPreviousResult() { try { debugLog(`Navigating to previous result from question ${currentResultQuestion + 1}`); if (currentResultQuestion > 0) { showResults(currentResultQuestion - 1); } } catch (e) { console.error("Error navigating to previous result:", e); debugLog("Failed to navigate to previous result: " + e.message); } } // Navigate to next result function showNextResult() { try { debugLog(`Navigating to next result from question ${currentResultQuestion + 1}`); if (currentResultQuestion < questions.length - 1) { showResults(currentResultQuestion + 1); } } catch (e) { console.error("Error navigating to next result:", e); debugLog("Failed to navigate to next result: " + e.message); } } // Lazy-load video function loadVideo(button, videoUrl, containerId) { try { debugLog(`Loading video for ${containerId}: ${videoUrl}`); if (!videoUrl) { const container = document.getElementById(containerId); container.innerHTML = `<p class="text-gray-500">No video available</p>`; button.remove(); debugLog("No video URL provided"); return; } const container = document.getElementById(containerId); container.innerHTML = ` <div class="video-loading"></div> <video controls class="w-full max-w-[600px] rounded-lg" preload="metadata" aria-label="Video explanation"> <source src="${videoUrl}" type="${videoUrl.endsWith('.m3u8') ? 'application/x-mpegURL' : 'video/mp4'}"> Your browser does not support the video tag. </video> `; container.classList.add('active'); button.remove(); // Initialize HLS.js for .m3u8 videos const video = container.querySelector('video'); if (videoUrl.endsWith('.m3u8') && Hls.isSupported()) { const hls = new Hls(); hls.loadSource(videoUrl); hls.attachMedia(video); hls.on(Hls.Events.ERROR, (event, data) => { console.error("HLS.js error:", data); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; debugLog("HLS.js error: " + JSON.stringify(data)); }); } else if (videoUrl.endsWith('.m3u8') && video.canPlayType('application/vnd.apple.mpegurl')) { video.src = videoUrl; } // Handle video load errors video.onerror = () => { console.error("Video load error for URL:", videoUrl); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; debugLog("Video load error for URL: " + videoUrl); }; // Remove loading spinner when video is ready video.onloadedmetadata = () => { container.querySelector('.video-loading').remove(); debugLog("Video loaded successfully"); }; } catch (e) { console.error("Error loading video:", e); debugLog("Failed to load video: " + e.message); const container = document.getElementById(containerId); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; } } // Lazy-load audio function loadAudio(button, audioUrl, containerId) { try { debugLog(`Loading audio for ${containerId}: ${audioUrl}`); if (!audioUrl) { const container = document.getElementById(containerId); container.innerHTML = `<p class="text-gray-500">No audio available</p>`; button.remove(); debugLog("No audio URL provided"); return; } const container = document.getElementById(containerId); container.innerHTML = ` <audio controls class="w-full max-w-[600px]" preload="metadata" aria-label="Audio explanation"> <source src="${audioUrl}" type="audio/mpeg"> Your browser does not support the audio tag. </audio> `; container.classList.add('active'); button.remove(); // Handle audio load errors const audio = container.querySelector('audio'); audio.onerror = () => { console.error("Audio load error for URL:", audioUrl); container.innerHTML = `<p class="text-red-500">Error loading audio. <a href="${audioUrl}" target="_blank" aria-label="Open audio in new tab">Open audio</a></p>`; debugLog("Audio load error for URL: " + audioUrl); }; debugLog("Audio loaded successfully"); } catch (e) { console.error("Error loading audio:", e); debugLog("Failed to load audio: " + e.message); const container = document.getElementById(containerId); container.innerHTML = `<p class="text-red-500">Error loading audio. <a href="${audioUrl}" target="_blank" aria-label="Open audio in new tab">Open audio</a></p>`; } } // Toggle dark mode function toggleTheme() { try { debugLog("Toggling theme"); document.documentElement.classList.toggle('dark'); localStorage.setItem('theme', document.documentElement.classList.contains('dark') ? 'dark' : 'light'); debugLog("Theme toggled successfully"); } catch (e) { console.error("Error toggling theme:", e); debugLog("Failed to toggle theme: " + e.message); } } // Load theme preference function loadTheme() { try { debugLog("Loading theme preference"); const theme = localStorage.getItem('theme'); if (theme === 'dark') { document.documentElement.classList.add('dark'); } debugLog("Theme loaded successfully"); } catch (e) { console.error("Error loading theme:", e); debugLog("Failed to load theme: " + e.message); } } // Initialize on DOM content loaded window.addEventListener('DOMContentLoaded', () => { try { debugLog("DOM content loaded, initializing quiz"); loadTheme(); initQuiz(); } catch (e) { console.error("Error during DOMContentLoaded:", e); debugLog("Failed to initialize on DOMContentLoaded: " + e.message); document.getElementById('error-message').innerHTML = "Error initializing quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); } }); </script> </body> </html>" frameborder="0" width="100%" height="2000px">
<div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <h2 class="text-xl font-semibold mb-4">Instructions</h2> <h4 class="text-gray-800 text-lg font-semibold mt-6 mb-4">Test Features:</h4> <ul class="space-y-3"> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Multiple choice questions with single correct answers </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Timer-based testing for realistic exam conditions </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Mark questions for review functionality </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Comprehensive results and performance analysis </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Mobile-optimized interface for learning on-the-go </li> </ul> <div class="mt-6 flex space-x-4 button-group md:flex-row flex-col"> <button class="bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="start-test">Start Test</button> </div> <div class="error-message hidden" id="error-message"></div> </div> </section> <!-- Quiz Section --> <section class="container mx-auto px-4 md:px-6 pt-4 md:pt-6 pb-1 hidden section-transition" id="quiz"> <div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <!-- Progress Bar --> <div class="w-full bg-gray-200 rounded-full h-3 mb-4"> <div class="progress-bar h-3 rounded-full" id="progress-bar" style="width: 0%"></div> </div> <!-- Question Header --> <div class="flex flex-col md:flex-row justify-between items-center mb-4"> <h2 class="text-lg font-semibold" id="question-number">Question <span>1</span> of 4</h2> <p class="text-lg font-semibold mt-2 md:mt-0" id="timer">Time Remaining: <span>00:00</span></p> </div> <!-- Question Content --> <div class="mb-6" id="question-content"> <p class="text-gray-800 mb-4" id="question-text"></p> <div class="flex flex-wrap gap-4 mb-4" id="question-images"></div> <div class="space-y-3" id="options"></div> </div> <!-- Navigation Buttons --> <div class="flex flex-col md:flex-row justify-between items-center gap-2 md:gap-4"> <div class="flex gap-2 w-full md:w-auto"> <button class="bg-[#2c5281] text-white px-4 py-3 w-full md:w-32 h-14 rounded-lg hover:bg-[#2c5281] transition" disabled="" id="previous-btn">Previous</button> <button class="bg-[#2c5281] text-white px-4 py-3 w-full md:w-32 h-14 rounded-lg hover:bg-[#2c5281] transition" id="next-btn">Next</button> </div> <div class="flex items-center gap-2"> <button class="bg-transparent text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-100 transition flex items-center gap-1" id="mark-review"> Review <svg xmlns="http://www.w3.org/2000/svg" class="h-5 w-5" viewBox="0 0 20 20" fill="currentColor"> <path d="M10 2a1 1 0 00-1 1v14l3.293-3.293a1 1 0 011.414 0L17 17V3a1 1 0 00-1-1H10z" /> </svg> </button> <button class="bg-transparent text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-100 transition flex items-center gap-1" id="nav-toggle"> Question 🧭 </button> <button class="bg-green-500 text-white px-6 py-3 w-44 h-14 rounded-lg hover:bg-green-600 transition w-full md:w-auto" id="submit-test">Submit Test</button> </div> </div> </section> <!-- Results Section --> <section class="container mx-auto px-4 md:px-6 pt-4 md:pt-6 pb-1 hidden section-transition" id="results"> <div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <h2 class="text-2xl font-semibold mb-4">Anaesthesia Machine - Results</h2> <div class="grid grid-cols-1 md:grid-cols-2 gap-4 mb-6"> <p><strong>Correct:</strong> <span id="correct-count" class="text-[#000000]">0</span></p> <p><strong>Wrong:</strong> <span id="wrong-count" class="text-[#000000]">0</span></p> <p><strong>Unanswered:</strong> <span id="unanswered-count" class="text-[#000000]-500">0</span></p> <p><strong>Marked for Review:</strong> <span id="marked-count" class="text-[#000000]">0</span></p> </div> <h3 class="text-lg font-semibold mb-4" id="result-question-number">Question <span>1</span> of 4</h3> <div class="space-y-6" id="results-content"></div> <div class="result-nav"> <button aria-label="Previous question result" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" disabled="" id="prev-result">Previous</button> <button aria-label="Toggle results navigation panel" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="results-nav-toggle">Result 🧭</button> <button aria-label="Next question result" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="next-result">Next</button> </div> <div class="mt-6 flex space-x-4 button-group md:flex-row flex-col"> <button class="bg-green-500 text-white px-6 py-2 rounded-lg hover:bg-green-600 transition" id="take-again">Take Again</button> </div> </div> </section> <!-- Exit Confirmation Modal --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 hidden" id="exit-modal" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white rounded-lg p-6 max-w-sm w-full"> <h2 class="text-xl font-semibold mb-4">Leave Test?</h2> <p class="text-gray-700 mb-4">Your progress will be lost if you leave this page. Are you sure you want to exit?</p> <div class="flex justify-end space-x-4"> <button class="bg-gray-300 text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-400 transition" id="continue-test">No, Continue</button> <button class="bg-red-500 text-white px-4 py-2 rounded-lg hover:bg-red-600 transition" id="exit-test">Yes, Exit</button> </div> </div> </div> <!-- Submit Confirmation Modal --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 hidden" id="submit-modal" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white rounded-lg p-6 max-w-sm w-full"> <h2 class="text-xl font-semibold mb-4">Confirm Submission</h2> <p class="text-gray-700 mb-2">You have attempted <span id="attempted-count">0</span> of 4 questions.</p> <p class="text-gray-700 mb-4"><span id="unattempted-count">0</span> questions are unattempted.</p> <div class="flex justify-end space-x-4"> <button class="bg-gray-300 text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-400 transition" id="cancel-submit">Cancel</button> <button class="text-white px-4 py-2 rounded-lg hover:bg-[#1a365d] transition" style="background-color: #2c5281;" id="confirm-submit">Submit Test</button> </div> </div> </div> <!-- Quiz Navigation Panel --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 z-50 nav-panel hidden overflow-y-auto" id="nav-panel" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white shadow-lg p-4 rounded-lg w-full max-w-2xl max-h-[80vh] overflow-y-auto"> <h2 class="text-lg font-semibold mb-4">Questions Navigation</h2> <div class="mb-4"> <select class="w-full p-2 border rounded-lg text-gray-700" id="nav-filter"> <option value="all">All Questions</option> <option value="answered">Answered</option> <option value="unanswered">Unanswered</option> <option value="marked">Marked for Review</option> </select> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-nav">Close</button> </div> </div> <!-- Results Navigation Panel --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 z-50 results-nav-panel hidden overflow-y-auto" id="results-nav-panel" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white shadow-lg p-4 rounded-lg w-full max-w-2xl max-h-[80vh] overflow-y-auto"> <h2 class="text-lg font-semibold mb-4">Results Navigation</h2> <div class="mb-4"> <select class="w-full p-2 border rounded-lg text-gray-700" id="results-nav-filter"> <option value="all">All Questions</option> <option value="answered">Answered</option> <option value="unanswered">Unanswered</option> <option value="marked">Marked for Review</option> </select> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="results-nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-results-nav">Close</button> </div> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="results-nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-results-nav">Close</button> </div> <!-- JavaScript Logic --> <script> // Enable debug mode for detailed logging const DEBUG_MODE = true; // Log debug messages function debugLog(message) { if (DEBUG_MODE) { console.log(`[DEBUG] ${message}`); } } // Initialize questions with error handling let questions = []; let currentResultQuestion = 0; // State for current question in results try { debugLog("Attempting to parse questions_json"); questions = [{"text": "Most common site of malignancy in oral cavity in India is?", "options": [{"label": "A", "text": "Tongue", "correct": false}, {"label": "B", "text": "Lip", "correct": false}, {"label": "C", "text": "Buccal mucosa", "correct": true}, {"label": "D", "text": "Floor of mouth", "correct": false}], "correct_answer": "C. Buccal mucosa", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Buccal mucosa</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ The most common site of malignancy in the oral cavity in India is the buccal mucosa , often attributed to the widespread use of carcinogenic substances like betel quid and gutka .</li><li>➤ most common site of malignancy</li><li>➤ oral cavity in India</li><li>➤ buccal mucosa</li><li>➤ widespread use of carcinogenic substances like betel quid and gutka</li><li>➤ Oral cancer is one of the most common cancers in India, with an age-adjusted incidence rate of 20 per 100 000. The disease accounts for over one-third of all cancers in India. In contrast to western populations, cancers of the Bucco gingival/ retromolar area account for over 40% of cancers in India and South East Asia , reflecting the commonplace use of the known carcinogens betel quid/gutka, along with smokeless tobacco. In Europe, there is significant variation where the lateral border of the tongue and the floor of the mouth constitute particularly high-risk sites.</li><li>➤ Oral cancer is one of the most common cancers in India, with an age-adjusted incidence rate of 20 per 100 000.</li><li>➤ The disease accounts for over one-third of all cancers in India.</li><li>➤ In contrast to western populations, cancers of the Bucco gingival/ retromolar area account for over 40% of cancers in India and South East Asia , reflecting the commonplace use of the known carcinogens betel quid/gutka, along with smokeless tobacco.</li><li>➤ cancers of the Bucco gingival/ retromolar area account for over 40% of cancers in India and South East Asia</li><li>➤ In Europe, there is significant variation where the lateral border of the tongue and the floor of the mouth constitute particularly high-risk sites.</li><li>➤ In Europe, there is significant variation where the lateral border of the tongue and the floor of the mouth constitute particularly high-risk sites.</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 813-814</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 813-814</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of these constitute cancers of oral cavity except?", "options": [{"label": "A", "text": "Lip", "correct": false}, {"label": "B", "text": "Floor of mouth", "correct": false}, {"label": "C", "text": "Retromolar trigone", "correct": false}, {"label": "D", "text": "Soft palate", "correct": true}], "correct_answer": "D. Soft palate", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Soft palate</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50 years old man came to the OPD for a routine annual check-up. He had no complaints. He has smoked cigarettes every day for the past few years. Oral examination reveals a thin, white patch with well-defined margins on the left upper hard palate. The resident attempts to scrape it off with a tongue depressor but cannot do so. What is the diagnosis?", "options": [{"label": "A", "text": "Squamous Cell Carcinoma", "correct": false}, {"label": "B", "text": "Thrush", "correct": false}, {"label": "C", "text": "Gingivitis", "correct": false}, {"label": "D", "text": "Leukoplakia", "correct": true}], "correct_answer": "D. Leukoplakia", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/18/picture1_PLM8AeK.jpg"], "explanation": "<p><strong>Ans. D) Leukoplakia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Squamous Cell Carcinoma - Squamous Cell Carcinoma is a type of oral cancer which can present as a white patch , it is typically not easily scraped off . However, it would show features like everted edges and spontaneous bleeding.</li><li>• Option A. Squamous Cell Carcinoma</li><li>• type of oral cancer</li><li>• can present as a white patch</li><li>• not easily scraped off</li><li>• Option B. Thrush - Thrush, or oral candidiasis , is a fungal infection characterized by white patches in the mouth. Unlike leukoplakia, it can be removed with a cotton swab.</li><li>• Option B. Thrush</li><li>• oral candidiasis</li><li>• fungal infection</li><li>• white patches in the mouth.</li><li>• Option C. Gingivitis - Gingivitis is an early stage of gum disease and typically does not present as a white patch on the palate.</li><li>• Option C. Gingivitis</li><li>• early stage of gum disease</li><li>• does not present as a white patch</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The diagnosis in this case is D. Leukoplakia . Leukoplakia is a premalignant condition often associated with tobacco use and presents as a white patch on the oral mucosa that cannot be easily scraped off . It requires close monitoring and evaluation for potential malignancy.</li><li>➤ D. Leukoplakia</li><li>➤ Leukoplakia</li><li>➤ premalignant condition</li><li>➤ associated with tobacco use</li><li>➤ presents as a white patch</li><li>➤ oral mucosa</li><li>➤ cannot be easily scraped off</li><li>➤ Oral leukoplakia is a premalignant lesion that presents as a white patch on the oral mucosa. It cannot be scrapped off . Risk factors include alcohol and tobacco (smoked and especially smokeless).</li><li>➤ premalignant lesion</li><li>➤ It cannot be scrapped off</li><li>➤ Ref: Bailey and Love Short Practice of Surgery 28th edition page 815-818.</li><li>➤ Ref:</li><li>➤ Bailey and Love Short Practice of Surgery 28th edition page 815-818.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these lesions in the oral cavity has the highest malignant potential?", "options": [{"label": "A", "text": "Leukoplakia", "correct": false}, {"label": "B", "text": "Speckled leukoplakia", "correct": true}, {"label": "C", "text": "Erythroplakia", "correct": false}, {"label": "D", "text": "Verrucous leukoplakia", "correct": false}], "correct_answer": "B. Speckled leukoplakia", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Speckled leukoplakia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Leukoplakia - Leukoplakia is a white patch or plaque on the oral mucosa that cannot be easily rubbed off. It has the potential to become malignant.</li><li>• Option A. Leukoplakia</li><li>• white patch or plaque on the oral mucosa</li><li>• Option C. Erythroplakia - Erythroplakia is a bright red velvety plaque on the oral mucosa and is known for its high malignant potential.</li><li>• Option C. Erythroplakia</li><li>• bright red velvety plaque on the oral mucosa</li><li>• Option D. Verrucous leukoplakia - Verrucous leukoplakia is a type of leukoplakia with a wart-like appearance. While it has malignant potential, it is not as high as speckled leukoplakia or erythroplakia.</li><li>• Option D. Verrucous leukoplakia</li><li>• type of leukoplakia with a wart-like appearance.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Among the given lesions, B. Speckled leukoplakia has the highest malignant potential. It is characterized by a combination of white and red patches and carries a significant risk of malignancy . Early evaluation and management are crucial for patients with speckled leukoplakia.</li><li>➤ B. Speckled leukoplakia</li><li>➤ highest malignant potential.</li><li>➤ combination of white and red patches</li><li>➤ carries a significant risk of malignancy</li><li>➤ High risk premalignant lesions for oral cancers: These lesions include leukoplakia, erythroplakia, erythro-leukoplakia, proliferative verrucous leukoplakia ( PVL) Moderate and low risk lesions include oral sub-mucous fibrosis, oral lichen planus and lupus erythematosus, as well as inherited conditions such as epidermolysis bullosa and dyskeratosis congenita. A leukoplakia is a white patch or plaque that cannot be rubbed of, while an erythroplakia is a bright red velvety plaque , neither of which can be characterized clinically or pathologically as any other recognizable condition. A speckled leukoplakia or erythro-leukoplakia is essentially a combination of both; it carries the greatest risk for malignant change.</li><li>➤ High risk premalignant lesions for oral cancers: These lesions include leukoplakia, erythroplakia, erythro-leukoplakia, proliferative verrucous leukoplakia ( PVL)</li><li>➤ High risk premalignant lesions for oral cancers:</li><li>➤ lesions</li><li>➤ leukoplakia, erythroplakia, erythro-leukoplakia, proliferative verrucous leukoplakia (</li><li>➤ Moderate and low risk lesions include oral sub-mucous fibrosis, oral lichen planus and lupus erythematosus, as well as inherited conditions such as epidermolysis bullosa and dyskeratosis congenita.</li><li>➤ A leukoplakia is a white patch or plaque that cannot be rubbed of, while an erythroplakia is a bright red velvety plaque , neither of which can be characterized clinically or pathologically as any other recognizable condition.</li><li>➤ A leukoplakia is a white patch or plaque</li><li>➤ that cannot be rubbed of, while an</li><li>➤ erythroplakia is a bright red velvety plaque</li><li>➤ A speckled leukoplakia or erythro-leukoplakia is essentially a combination of both; it carries the greatest risk for malignant change.</li><li>➤ Factors associated with increased risk for malignant change in pre-existing (dysplastic) lesions:</li><li>➤ Factors associated with increased risk for malignant change in pre-existing (dysplastic) lesions:</li><li>➤ Female sex Size &gt; 200 mm 2 Non-homogeneous lesion May be higher in smokers (although contradictory evidence exists to suggest non-smokers are at higher risk) Presence of multiple lesions Location (e.g., lateral border of tongue/floor of mouth)</li><li>➤ Female sex</li><li>➤ Female sex</li><li>➤ Size &gt; 200 mm 2</li><li>➤ &gt; 200 mm 2</li><li>➤ Non-homogeneous lesion</li><li>➤ Non-homogeneous lesion</li><li>➤ May be higher in smokers (although contradictory evidence exists to suggest non-smokers are at higher risk)</li><li>➤ higher in smokers</li><li>➤ Presence of multiple lesions</li><li>➤ Presence of multiple lesions</li><li>➤ Location (e.g., lateral border of tongue/floor of mouth)</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 815</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 815</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 60 years old man comes with a thin, white patch with well-defined margins on the left lateral aspect of tongue. The resident attempts to scrape it off with a tongue depressor but cannot do so. Which of the following is the most likely etiology of this patient’s condition?", "options": [{"label": "A", "text": "Submandibular stones", "correct": false}, {"label": "B", "text": "Inhaled corticosteroids", "correct": false}, {"label": "C", "text": "Poor oral hygiene", "correct": false}, {"label": "D", "text": "History of cigarette smoking", "correct": true}], "correct_answer": "D. History of cigarette smoking", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) History of cigarette smoking</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Submandibular stones – They are associated with swelling and pain at angle of mandible, typically after meals. They do not lead to white patch on tongue.</li><li>• Option A. Submandibular stones</li><li>• swelling and pain at angle of mandible,</li><li>• after meals.</li><li>• Option B. Inhaled corticosteroids - Inhaled corticosteroids can lead to oral thrush , but this condition can be easily scraped off with a tongue depressor. It is not the most likely etiology for the patient's condition.</li><li>• Option B. Inhaled corticosteroids</li><li>• lead to oral thrush</li><li>• easily scraped off with a tongue depressor.</li><li>• Option C. Poor oral hygiene - Poor oral hygiene can contribute to various oral conditions, but it is not the most likely cause of a well-defined white patch that cannot be scraped off.</li><li>• Option C. Poor oral hygiene</li><li>• contribute to various oral conditions,</li><li>• not the most likely cause of a well-defined white patch</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In a patient with a well-defined white patch on the oral mucosa that cannot be scraped off , the most likely etiology is D. History of cigarette smoking , which is associated with leukoplakia, a premalignant lesion . A biopsy is necessary to determine the extent of dysplasia and the need for further management.</li><li>➤ patient with a well-defined white patch</li><li>➤ oral mucosa that cannot be scraped off</li><li>➤ D. History of cigarette smoking</li><li>➤ associated with leukoplakia, a premalignant lesion</li><li>➤ Oral leukoplakia is a premalignant lesion that presents as a white patch on the oral mucosa. It cannot be scrapped off . Risk factors include alcohol and tobacco (smoked and especially smokeless). It is a premalignant lesion and a biopsy is necessary to determine the extent of dysplasia. Oral hairy leukoplakia is an EBV mediated muco-cutaneous condition in which virus most commonly infects the squamous epithelium of the tongue. It presents as a white lesion on the lateral margin of the tongue with feathery margins. Inhaled steroids related thrush can be easily scraped off with a tongue depressor. Erythro-leukoplakia, PVL and dyskeratosis congenita carry the highest risk for malignant transformation. Clinical factors to be considered include size, location and lifestyle exposure to known carcinogens. Biopsy of lesions is advocated for accurate pathological diagnosis as well as to ascertain the degree of dysplasia (mild, moderate, severe), or indeed the presence of malignancy in a lesion. Surgical removal of a premalignant or dysplastic lesion does not completely remove the risk of transformation and as such appropriate surveillance regimes are necessary.</li><li>➤ Oral leukoplakia is a premalignant lesion that presents as a white patch on the oral mucosa. It cannot be scrapped off . Risk factors include alcohol and tobacco (smoked and especially smokeless). It is a premalignant lesion and a biopsy is necessary to determine the extent of dysplasia.</li><li>➤ Oral leukoplakia is a premalignant lesion</li><li>➤ white patch</li><li>➤ cannot be scrapped off</li><li>➤ premalignant lesion</li><li>➤ Oral hairy leukoplakia is an EBV mediated muco-cutaneous condition in which virus most commonly infects the squamous epithelium of the tongue. It presents as a white lesion on the lateral margin of the tongue with feathery margins.</li><li>➤ Oral hairy leukoplakia</li><li>➤ EBV mediated muco-cutaneous condition</li><li>➤ Inhaled steroids related thrush can be easily scraped off with a tongue depressor.</li><li>➤ Inhaled steroids related thrush can be easily scraped off with a tongue depressor.</li><li>➤ Erythro-leukoplakia, PVL and dyskeratosis congenita carry the highest risk for malignant transformation. Clinical factors to be considered include size, location and lifestyle exposure to known carcinogens. Biopsy of lesions is advocated for accurate pathological diagnosis as well as to ascertain the degree of dysplasia (mild, moderate, severe), or indeed the presence of malignancy in a lesion.</li><li>➤ Surgical removal of a premalignant or dysplastic lesion does not completely remove the risk of transformation and as such appropriate surveillance regimes are necessary.</li><li>➤ Surgical removal of a premalignant</li><li>➤ dysplastic lesion does not completely remove the risk of transformation</li><li>➤ Ref: Bailey and Love Short Practice of Surgery 28th edition page 815</li><li>➤ Ref:</li><li>➤ Bailey and Love Short Practice of Surgery 28th edition page 815</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient with cheek cancer has a tumour of 2.5cm located close to and involving the lower alveolus. A single mobile ipsilateral lymph node measuring 5 cm is palpable. What is the TNM stage of this tumour?", "options": [{"label": "A", "text": "T2N1M0", "correct": false}, {"label": "B", "text": "T2N2M0", "correct": false}, {"label": "C", "text": "T4N1M0", "correct": false}, {"label": "D", "text": "T4N2M0", "correct": true}], "correct_answer": "D. T4N2M0", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/18/picture2_wmgJK7n.jpg"], "explanation": "<p><strong>Ans. D) T4N2M0</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Tumor involving lower alveolar margin is T4 . Single ipsilateral LN of 5 cm is N2 .</li><li>• lower alveolar margin is T4</li><li>• Single ipsilateral LN of 5 cm is N2</li><li>• .</li><li>• N STAGING</li><li>• N1 – Single or multiple, not more than 3 cm (ipsilateral only) N2 – Single or multiple, between 3-6 cm or bilateral up to 6 cm N3 - &gt;6 cm Extra nodal extension (ENE): N will be upstaged BY ONE LEVEL</li><li>• N1 – Single or multiple, not more than 3 cm (ipsilateral only)</li><li>• N1</li><li>• not more than 3 cm</li><li>• N2 – Single or multiple, between 3-6 cm or bilateral up to 6 cm</li><li>• N2</li><li>• between 3-6 cm</li><li>• bilateral up to 6 cm</li><li>• N3 - &gt;6 cm</li><li>• N3</li><li>• &gt;6 cm</li><li>• Extra nodal extension (ENE): N will be upstaged BY ONE LEVEL</li><li>• Extra nodal extension</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective :</li><li>➤ As given in the case above Tumor involving lower alveolar margin is T4 . Single ipsilateral LN of 5 cm is N2 . Hence answer is T4N2M0.</li><li>➤ As given in the case above</li><li>➤ lower alveolar margin is T4</li><li>➤ Single ipsilateral LN of 5 cm is N2</li><li>➤ . Hence answer is T4N2M0.</li><li>➤ Ref: Bailey 28 th Ed. Pg 816-817</li><li>➤ Ref:</li><li>➤ Bailey 28 th Ed. Pg 816-817</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is false regarding risk factors for oral cancer?", "options": [{"label": "A", "text": "Hyperkeratosis and parakeratosis are seen in leukoplakia", "correct": false}, {"label": "B", "text": "Speckled erythroplakia is having lower risk of malignant transformation than erythroplakia", "correct": true}, {"label": "C", "text": "Erythroplakia lesions with moderate to severe dysplasia should be excised", "correct": false}, {"label": "D", "text": "Proliferative verrucous leukoplakia (PVL) is highly malignant", "correct": false}], "correct_answer": "B. Speckled erythroplakia is having lower risk of malignant transformation than erythroplakia", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Speckled erythroplakia is having lower risk of malignant transformation than erythroplakia.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Hyperkeratosis and parakeratosis are seen in leukoplakia - This statement is true . Leukoplakia is a premalignant lesion that can exhibit hyperkeratosis, which is characterized by excessive keratinization of the epithelium. Parakeratosis, which involves the retention of nuclei in the stratum corneum, can also be seen in leukoplakia.</li><li>• Option A. Hyperkeratosis and parakeratosis are seen in leukoplakia</li><li>• true</li><li>• Option C. Erythroplakia lesions with moderate to severe dysplasia should be excised - This statement is generally true . Erythroplakia lesions with moderate to severe dysplasia are considered high-risk and are often recommended for excision to prevent malignant transformation.</li><li>• Option C. Erythroplakia lesions with moderate to severe dysplasia should be excised</li><li>• true</li><li>• Option D. Proliferative verrucous leukoplakia (PVL) is highly malignant - This statement is true . Proliferative verrucous leukoplakia (PVL) is a subtype of leukoplakia that is characterized by its high potential for malignant transformation. It is indeed considered highly malignant.</li><li>• Option D. Proliferative verrucous leukoplakia (PVL) is highly malignant</li><li>• true</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Parakeratosis is a mode of keratinisation characterised by the retention of nuclei in the stratum corner . Oral frictional hyperkeratosis is a benign white lesion of the oral mucosa caused by chronic trauma to the site. Basic microscopic characteristics of oral leukoplakia include hyperkeratosis of ortho or parakeratotic type and acanthuses of the epithelium , with various degrees of chronic inflammatory infiltrates in lamina propria Speckled erythroplakia has higher risk than erythroplakia Moderate to severe epithelial dysplasia is usually treated by removing the patch surgically or laser treatment Erythroleukoplakia, PVL and dyskeratosis congenita carry the highest risk for malignant transformation.</li><li>➤ Parakeratosis is a mode of keratinisation characterised by the retention of nuclei in the stratum corner . Oral frictional hyperkeratosis is a benign white lesion of the oral mucosa caused by chronic trauma to the site.</li><li>➤ Parakeratosis</li><li>➤ mode of keratinisation</li><li>➤ retention of nuclei</li><li>➤ stratum corner</li><li>➤ Basic microscopic characteristics of oral leukoplakia include hyperkeratosis of ortho or parakeratotic type and acanthuses of the epithelium , with various degrees of chronic inflammatory infiltrates in lamina propria</li><li>➤ Basic microscopic</li><li>➤ oral leukoplakia</li><li>➤ hyperkeratosis of ortho</li><li>➤ parakeratotic type</li><li>➤ acanthuses of the epithelium</li><li>➤ Speckled erythroplakia has higher risk than erythroplakia</li><li>➤ Speckled erythroplakia</li><li>➤ higher risk than erythroplakia</li><li>➤ Moderate to severe epithelial dysplasia is usually treated by removing the patch surgically or laser treatment</li><li>➤ Moderate to severe epithelial dysplasia</li><li>➤ removing the patch surgically or laser treatment</li><li>➤ Erythroleukoplakia, PVL and dyskeratosis congenita carry the highest risk for malignant transformation.</li><li>➤ Ref : Bailey and Love Short Practice of Surgery 28th edition page 815</li><li>➤ Ref</li><li>➤ : Bailey and Love Short Practice of Surgery 28th edition page 815</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 44-year-old female came to the OPD complaining of tingling of lips. She also had a slightly raised whitish discolouration of the lip and a sore on the lip that did not heal. What is correct about Ca lip among the following?", "options": [{"label": "A", "text": "Non healing ulcers or growth is the most common presentation", "correct": true}, {"label": "B", "text": "The most common site is vermillion border of upper lip", "correct": false}, {"label": "C", "text": "Abbe flap is a type of pedicled distant flap", "correct": false}, {"label": "D", "text": "Abbe-Estlander flap is based on the inferior labial artery", "correct": false}], "correct_answer": "A. Non healing ulcers or growth is the most common presentation", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/18/picture3_PcqEMgp.jpg"], "explanation": "<p><strong>Ans. A) Non healing ulcers or growth is the most common presentation</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. The most common site is vermillion of the upper lip - This statement is incorrect . The most common site for lip cancer is the vermillion of the lower lip , not the upper lip. Approximately 80 to 95% of lip cancers occur in the lower lip.</li><li>• Option B. The most common site is vermillion of the upper lip</li><li>• incorrect</li><li>• lower lip</li><li>• Option C. Abbe flap is a type of pedicled distant flap - This statement is incorrect . The Abbe flap is a type of local flap . It is commonly employed in the repair of lip defects.</li><li>• Option C. Abbe flap is a type of pedicled distant flap</li><li>• incorrect</li><li>• local flap</li><li>• Option D. Abbe-Estlander flap is based on the inferior labial artery - This statement is incorrect . The Abbe-Estlander flap is based on the superior labial artery , not the inferior labial artery.</li><li>• Option D. Abbe-Estlander flap is based on the inferior labial artery</li><li>• incorrect</li><li>• superior labial artery</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In cases of lip cancer, it is important to recognize that the most common presentation is A. Non-healing ulcers or growth on the lip. Additionally, understanding the use of surgical techniques like the Abbe flap in lip reconstruction is crucial for managing lip defects resulting from cancer excision.</li><li>➤ A. Non-healing ulcers or growth</li><li>➤ Abbe flap</li><li>➤ Lip cancer</li><li>➤ Lip cancer</li><li>➤ Often looks like a mouth sore that won’t heal. The most common site is vermillion of lower lip (80 to 95%) followed by upper lip (2 to 12%) and commissure (1 to 15%) If 1/3rd or less of the lip is involved then V or W shaped full thickness excision with a lateral margin of 5mm plus primary closure is the treatment of choice For larger defects, Abbe-Estlander flaps are used, which are LOCAL FLAPS. The flap is fed by the opposite superior labial artery which is a full thickness triangular shaped upper lip flap that creates the oral commissure and lateral part of the lower lip.</li><li>➤ Often looks like a mouth sore that won’t heal.</li><li>➤ The most common site is vermillion of lower lip (80 to 95%) followed by upper lip (2 to 12%) and commissure (1 to 15%)</li><li>➤ most common site is vermillion of lower lip</li><li>➤ followed by upper lip</li><li>➤ and commissure</li><li>➤ If 1/3rd or less of the lip is involved then V or W shaped full thickness excision with a lateral margin of 5mm plus primary closure is the treatment of choice</li><li>➤ For larger defects, Abbe-Estlander flaps are used, which are LOCAL FLAPS. The flap is fed by the opposite superior labial artery which is a full thickness triangular shaped upper lip flap that creates the oral commissure and lateral part of the lower lip.</li><li>➤ For larger defects, Abbe-Estlander flaps are used, which are LOCAL FLAPS.</li><li>➤ Ref: Bailey and Love Short Practice of Surgery 27th edition page 765,768, 769</li><li>➤ Ref:</li><li>➤ Bailey and Love Short Practice of Surgery 27th edition page 765,768, 769</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient has small, oval multiple painful ulcers in the oral cavity with red erythematous margins. She has tingling sensation in the ulcers. She also has a history of megaloblastic anemia. What is the diagnosis?", "options": [{"label": "A", "text": "Carcinoma", "correct": false}, {"label": "B", "text": "Tubercular ulcer", "correct": false}, {"label": "C", "text": "Aphthous ulcer", "correct": true}, {"label": "D", "text": "Syphilitic ulcer", "correct": false}], "correct_answer": "C. Aphthous ulcer", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Aphthous ulcer</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Carcinoma - This option is unlikely because carcinomas typically present as malignant growths or tumors , which are typically painless.</li><li>• Option A. Carcinoma</li><li>• carcinomas typically present as malignant growths or tumors</li><li>• Option B. Tubercular ulcer - This option is not consistent with the presentation described. Tubercular ulcers are firm , non-tender erythematous nodules that eventually ulcerate and form sinuses . They do not typically cause painful ulcers with tingling sensations.</li><li>• Option B. Tubercular ulcer</li><li>• Tubercular ulcers are firm</li><li>• non-tender erythematous nodules</li><li>• ulcerate</li><li>• form sinuses</li><li>• Option D. Syphilitic ulcer - This option is not a likely diagnosis based on the patient's symptoms. Syphilitic ulcers are typically painless and non-itchy , which is different from the painful ulcers described.</li><li>• Option D. Syphilitic ulcer</li><li>• Syphilitic ulcers</li><li>• painless and non-itchy</li><li>• different from the painful ulcers</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The patient's presentation, including small, oval, painful ulcers with red erythematous margins and tingling sensations , is characteristic of C. Aphthous ulcers . These ulcers can be associated with various factors, including vitamin deficiencies like B12 deficiency .</li><li>➤ small, oval, painful ulcers</li><li>➤ red erythematous margins</li><li>➤ tingling sensations</li><li>➤ C. Aphthous ulcers</li><li>➤ vitamin deficiencies like B12 deficiency</li><li>➤ Ref: Bailey and Love Short Practice of Surgery 27th edition page 768</li><li>➤ Ref: Bailey and Love Short Practice of Surgery 27th edition page 768</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 60-year-old man comes to the OPD with a lesion on his lower lip that developed over the past year. He works as a gardener and reports infrequent use of sun protection. On examination, a 5mm erythematous ulcerative module within the vermillion border of the right lateral aspect of lower lip. Biopsy confirms SCC. Which lymph nodes would be most critical to evaluate for metastasis before surgery?", "options": [{"label": "A", "text": "Posterior triangle", "correct": false}, {"label": "B", "text": "Submandibular lymph nodes", "correct": true}, {"label": "C", "text": "Central compartment", "correct": false}, {"label": "D", "text": "Pre-auricular", "correct": false}], "correct_answer": "B. Submandibular lymph nodes", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Submandibular lymph nodes</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Posterior triangle - The posterior triangle typically contains lymph nodes associated with the posterior cervical chain (level V). These nodes are not the most critical for evaluating metastasis in lower lip SCC , as lymphatic drainage from the lower lip is directed to other regional lymph nodes. Posterior triangle nodes like supraclavicular group are involved in cancers of breast, lung apex etc.</li><li>• Option A. Posterior triangle</li><li>• lymph nodes</li><li>• posterior cervical chain</li><li>• These nodes are not the most critical for evaluating metastasis in lower lip SCC</li><li>• Option C Central compartment - The central compartment typically refers to lymph nodes in the central neck area , including levels VI and VII . This region is not the primary drainage site for lower lip SCC. It usually is involved in thyroid and laryngeal cancers.</li><li>• Option C Central compartment</li><li>• lymph nodes in the central neck area</li><li>• levels VI and VII</li><li>• Option D Pre-auricular - The pre-auricular lymph nodes are located in front of the ear and are not typically the primary site for metastasis in lower lip SCC.</li><li>• Option D Pre-auricular</li><li>• located in front of the ear</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In cases of lower lip SCC , the most critical lymph nodes to evaluate for metastasis before surgery are the B. Submandibular lymph nodes (level Ib) . Lymphatic drainage from the lower lip , including the lateral aspects, directs towards these nodes , making them the primary site for metastasis evaluation.</li><li>➤ lower lip SCC</li><li>➤ lymph nodes to evaluate for metastasis before surgery</li><li>➤ B. Submandibular lymph nodes (level Ib)</li><li>➤ Lymphatic drainage</li><li>➤ lower lip</li><li>➤ lateral aspects, directs towards these nodes</li><li>➤ primary site for metastasis evaluation.</li><li>➤ Lip carcinoma most commonly involves the vermillion border of lower lip away from the line of contact with the upper lip. The tumours spread laterally rather than through deep infiltration. Uncontrolled tumours can spread into the anterior triangle of the neck and can invade the mandible. Lymph node metastasis occurs late. Therefore, surgery and radiotherapy are frequently employed and are highly effective methods of treatment, each giving cure rates of about 90%. Lymphatic drainage from upper lip and lateral aspects of lower lip is directed to the ipsilateral submandibular lymph nodes (Ib) SCC in the oral cavity and lips tends to metastasise to lymph nodes at levels I, II and, to a lesser extent, level III unless higher levels are also positive. For SCC of tongue, metastasis may occur directly to lymph node levels III or IV, without the involvement of higher-level lymph node groups. Importantly, there is also a recognised risk of contralateral neck metastasis even in well lateralised tumours of the oral tongue . Tumors arising in the oropharynx commonly metastasise to lymph node levels II, III and IV, as well as retropharyngeal and contralateral nodal groups The thyroid, parathyroid and cervical part of esophagus and larynx drain into the posterior cervical chain (level V) The central portion of lower lip drains into the sub-mental lymph nodes (Ia)</li><li>➤ Lip carcinoma most commonly involves the vermillion border of lower lip away from the line of contact with the upper lip. The tumours spread laterally rather than through deep infiltration.</li><li>➤ Lip carcinoma most commonly involves the vermillion border of lower lip</li><li>➤ The tumours spread laterally</li><li>➤ Uncontrolled tumours can spread into the anterior triangle of the neck and can invade the mandible.</li><li>➤ Lymph node metastasis occurs late.</li><li>➤ Therefore, surgery and radiotherapy are frequently employed and are highly effective methods of treatment, each giving cure rates of about 90%.</li><li>➤ surgery and radiotherapy are frequently employed and are highly effective</li><li>➤ Lymphatic drainage from upper lip and lateral aspects of lower lip is directed to the ipsilateral submandibular lymph nodes (Ib)</li><li>➤ (Ib)</li><li>➤ SCC in the oral cavity and lips tends to metastasise to lymph nodes at levels I, II and, to a lesser extent, level III unless higher levels are also positive.</li><li>➤ SCC in the oral cavity and lips tends to metastasise to lymph nodes at levels I, II and, to a lesser extent, level III unless higher levels are also positive.</li><li>➤ For SCC of tongue, metastasis may occur directly to lymph node levels III or IV, without the involvement of higher-level lymph node groups. Importantly, there is also a recognised risk of contralateral neck metastasis even in well lateralised tumours of the oral tongue .</li><li>➤ Importantly, there is also a recognised risk of contralateral neck metastasis even in well lateralised tumours of the oral tongue</li><li>➤ Tumors arising in the oropharynx commonly metastasise to lymph node levels II, III and IV, as well as retropharyngeal and contralateral nodal groups</li><li>➤ The thyroid, parathyroid and cervical part of esophagus and larynx drain into the posterior cervical chain (level V)</li><li>➤ (level V)</li><li>➤ The central portion of lower lip drains into the sub-mental lymph nodes (Ia)</li><li>➤ (Ia)</li><li>➤ Ref: Bailey and Love Short Practice of Surgery 27th edition page 764, Bailey 28 th Ed. Pg 815-816</li><li>➤ Ref: Bailey and Love Short Practice of Surgery 27th edition page 764, Bailey 28 th Ed. Pg 815-816</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "According to MSKCC classification of neck nodes, Level IIA nodes represent?", "options": [{"label": "A", "text": "Submandibular group", "correct": false}, {"label": "B", "text": "Nodes above angle of mandible and anterior to XIth Nerve", "correct": false}, {"label": "C", "text": "Nodes above hyoid and anterior to XIth nerve", "correct": true}, {"label": "D", "text": "Nodes above hyoid and posterior to XIth nerve", "correct": false}], "correct_answer": "C. Nodes above hyoid and anterior to XIth nerve", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/18/picture5_l4rSy7N.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/18/picture4.png"], "explanation": "<p><strong>Ans. C) Nodes above hyoid and anterior to XIth nerve</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• The level II nodes (above hyoid), which contain the large jugulodigastric node , drain the naso- and oropharynx , including the tonsils, posterolateral aspects of the oral cavity and the superior aspects of the larynx and piriform fossae. They are the most common sites of enlargement and may be palpated along the anterior border of the sternocleidomastoid muscle.</li><li>• The level II nodes (above hyoid), which contain the large jugulodigastric node , drain the naso- and oropharynx , including the tonsils, posterolateral aspects of the oral cavity and the superior aspects of the larynx and piriform fossae. They are the most common sites of enlargement and may be palpated along the anterior border of the sternocleidomastoid muscle.</li><li>• level II nodes</li><li>• large jugulodigastric node</li><li>• drain</li><li>• naso- and oropharynx</li><li>• tonsils, posterolateral aspects of the oral cavity</li><li>• They are the most common sites of enlargement</li><li>• palpated along the anterior border of the sternocleidomastoid muscle.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ :</li><li>➤ According to MSKCC classification of neck nodes, Level IIA nodes represent nodes above hyoid and anterior to XIth nerve.</li><li>➤ nodes above hyoid and anterior to XIth nerve.</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 778.</li><li>➤ Ref:</li><li>➤ Bailey and Love, 28 th Ed. Pg 778.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Imaging modality of choice for local staging including perineural invasion in oral malignancy?", "options": [{"label": "A", "text": "USG", "correct": false}, {"label": "B", "text": "CECT", "correct": false}, {"label": "C", "text": "MRI", "correct": true}, {"label": "D", "text": "PET CT", "correct": false}], "correct_answer": "C. MRI", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) MRI</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. USG (Ultrasonography) - While ultrasound can be useful for evaluating certain aspects of oral lesions , such as assessing cervical lymph nodes for metastasis , it is not typically the primary imaging modality for diagnosing oral malignancy . Ultrasound lacks the detailed soft tissue contrast of other imaging methods.</li><li>• Option A. USG (Ultrasonography)</li><li>• evaluating certain aspects of oral lesions</li><li>• assessing cervical lymph nodes for metastasis</li><li>• not</li><li>• primary imaging modality</li><li>• diagnosing oral malignancy</li><li>• Option B. CECT (Contrast-Enhanced Computed Tomography) - CECT is a valuable imaging modality for assessing head and neck cancers , including those in the oral cavity . It provides detailed cross-sectional images and is often used for staging and evaluating the extent of the tumor. However, it may not provide the same soft tissue contrast as MRI.</li><li>• Option B. CECT (Contrast-Enhanced Computed Tomography)</li><li>• valuable imaging modality</li><li>• assessing head and neck cancers</li><li>• oral cavity</li><li>• cross-sectional images</li><li>• Option D. PET CT (Positron Emission Tomography-Computed Tomography) - PET CT can be useful in cancer diagnosis , but it is often used for staging and assessing metastasis rather than the primary diagnosis of oral malignancy . It provides functional information about glucose metabolism in tissues.</li><li>• Option D. PET CT (Positron Emission Tomography-Computed Tomography)</li><li>• useful in cancer diagnosis</li><li>• used for staging and assessing metastasis</li><li>• primary diagnosis of oral malignancy</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ For the diagnosis of oral malignancy, C. MRI (Magnetic Resonance Imaging) is the imaging modality of choice, offering superior soft tissue contrast resolution and valuable information for defining the extent of the tumor.</li><li>➤ C. MRI (Magnetic Resonance Imaging)</li><li>➤ For primary diagnosis: Histopathological diagnosis via a formal biopsy is the gold standard prior to further investigation and treatment . An edge/wedge biopsy is preferred.</li><li>➤ For primary diagnosis: Histopathological diagnosis</li><li>➤ gold standard</li><li>➤ . An edge/wedge biopsy is preferred.</li><li>➤ Contemporary cross-sectional imaging techniques are essential in the management of head and neck cancer. They inform treatment decisions and prognosis. CT and/or MRI are the gold standard imaging modalities to stage a tumour of the oral cavity. Plain film radiography and ultrasonography, along with positron emission tomography–computed tomography (PETCT) are useful adjuncts. By comparison with CT, MRI has improved soft-tissue contrast resolution and, depending upon specialist radiologist preference, it is frequently the imaging modality of choice for defining the primary extent of oral cavity cancers . Additionally, it offers more information on peri-neural spread and bone marrow invasion. CT: Hard-tissue detail is a particular advantage of CT, relative to MRI; this is particularly important when assessing bony involvement (mandible/maxilla) in oral SCC. CT is also the usual imaging modality for thoracic staging.</li><li>➤ Contemporary cross-sectional imaging techniques are essential in the management of head and neck cancer. They inform treatment decisions and prognosis.</li><li>➤ CT and/or MRI are the gold standard imaging modalities to stage a tumour of the oral cavity.</li><li>➤ CT and/or MRI are the gold standard imaging modalities to stage a tumour of the oral cavity.</li><li>➤ Plain film radiography and ultrasonography, along with positron emission tomography–computed tomography (PETCT) are useful adjuncts.</li><li>➤ By comparison with CT, MRI has improved soft-tissue contrast resolution and, depending upon specialist radiologist preference, it is frequently the imaging modality of choice for defining the primary extent of oral cavity cancers . Additionally, it offers more information on peri-neural spread and bone marrow invasion.</li><li>➤ it is frequently the imaging modality of choice for defining the primary extent of oral cavity cancers</li><li>➤ on peri-neural spread</li><li>➤ CT: Hard-tissue detail is a particular advantage of CT, relative to MRI; this is particularly important when assessing bony involvement (mandible/maxilla) in oral SCC. CT is also the usual imaging modality for thoracic staging.</li><li>➤ CT:</li><li>➤ important when assessing bony involvement (mandible/maxilla)</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 819-820</li><li>➤ Ref:</li><li>➤ Bailey and Love, 28 th Ed. Pg 819-820</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is not a standard approach to access tongue malignancies during resection?", "options": [{"label": "A", "text": "Intra oral", "correct": false}, {"label": "B", "text": "Visor flap approach", "correct": false}, {"label": "C", "text": "Lip split mandibulotomy", "correct": false}, {"label": "D", "text": "Abbe-Estlander approach", "correct": true}], "correct_answer": "D. Abbe-Estlander approach", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/picture1.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/picture2.jpg"], "explanation": "<p><strong>Ans. D) Abbe-Estlander approach</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Intraoral - This is a standard approach for resecting tongue malignancies . It involves accessing and removing the tumor through the mouth , often using transoral surgery techniques.</li><li>• Option A. Intraoral</li><li>• standard approach</li><li>• resecting tongue malignancies</li><li>• accessing and removing the tumor through the mouth</li><li>• Option B. Visor Flap Approach - The visor flap approach is a surgical technique used to access and resect tongue malignancies . It involves creating a flap from the neck to enter into oral cavity.</li><li>• Option B. Visor Flap Approach</li><li>• surgical technique</li><li>• access and resect tongue malignancies</li><li>• Option C. Lip Split Mandibulotomy - Lip split mandibulotomy is a standard surgical approach for accessing and resecting large or posteriorly located tongue tumors . It involves making an incision in the lower lip and mandible to access the tumor.</li><li>• Option C. Lip Split Mandibulotomy</li><li>• standard surgical approach for accessing and resecting large or posteriorly located tongue tumors</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Among the given options, D. Abbe-Estlander approach is not a standard approach for accessing tongue malignancies during resection . Standard approaches include intraoral, visor flap, and lip split mandibulotomy techniques.</li><li>➤ D. Abbe-Estlander approach</li><li>➤ not a standard approach for accessing tongue malignancies</li><li>➤ resection</li><li>➤ While most tumours can be removed via a transoral approach , some cannot be resected safely without an access procedure. These might include large maxillary tumours, posteriorly located tumours and tongue base tumours, or patients who have previously had surgery and/or radiotherapy. The most commonly used access procedures include the lip-split mandibulotomy (LSM), the mandibular lingual release, the visor flap and the Weber–Fergusson approach.</li><li>➤ While most tumours can be removed via a transoral approach , some cannot be resected safely without an access procedure. These might include large maxillary tumours, posteriorly located tumours and tongue base tumours, or patients who have previously had surgery and/or radiotherapy.</li><li>➤ While most tumours can be removed via a transoral approach</li><li>➤ The most commonly used access procedures include the lip-split mandibulotomy (LSM), the mandibular lingual release, the visor flap and the Weber–Fergusson approach.</li><li>➤ The most commonly used access procedures include the lip-split mandibulotomy (LSM), the mandibular lingual release, the visor flap and the Weber–Fergusson approach.</li><li>➤ Lip split mandibulotomy</li><li>➤ Lip split mandibulotomy</li><li>➤ Visor flap approach</li><li>➤ Visor flap approach</li><li>➤ Ref: Bailey and Love, 28 th ed. Pg 821.</li><li>➤ Ref:</li><li>➤ Bailey and Love, 28 th ed. Pg 821.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old male tobacco chewer came to the hospital with a SCC of tongue. Staging revealed T3N1 cancer with peri-neural invasion. Which of the following is the most probable treatment?", "options": [{"label": "A", "text": "Radiation therapy", "correct": false}, {"label": "B", "text": "Chemotherapy", "correct": false}, {"label": "C", "text": "Surgery and chemo-radiation", "correct": true}, {"label": "D", "text": "Chemotherapy and radiation", "correct": false}], "correct_answer": "C. Surgery and chemo-radiation", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Surgery and chemo-radiation</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Radiation therapy - Radiation therapy alone is not the most probable treatment for this advanced stage of tongue cancer . It may be used as part of a combined treatment approach.</li><li>• Option A. Radiation therapy</li><li>• alone is not the most probable treatment for this advanced stage of tongue cancer</li><li>• Option B. Chemotherapy - Chemotherapy alone is not typically the primary treatment for localized tongue cancer. It is often used as an adjuvant therapy or in combination with radiation or surgery.</li><li>• Option B. Chemotherapy</li><li>• not typically the primary treatment for localized tongue cancer.</li><li>• Option D. Chemotherapy and radiation - This combination is often used as adjuvant therapy after surgery in some cases but may not be the most probable initial treatment for T3N1 tongue cancer with peri-neural invasion.</li><li>• Option D. Chemotherapy and radiation</li><li>• used as adjuvant therapy after surgery in some cases</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most probable treatment for T3N1 tongue cancer with peri-neural invasion is C. Surgery and chemo-radiation . This combined approach aims to address both the primary tumor and regional lymph node involvement while providing adjuvant therapy to reduce the risk of recurrence.</li><li>➤ most probable treatment for T3N1 tongue cancer</li><li>➤ peri-neural invasion</li><li>➤ C. Surgery and chemo-radiation</li><li>➤ combined approach aims to address both the primary tumor and regional lymph node</li><li>➤ The gold standard in Oral cavity SCC is resection with a 1 cm clinical margin circumferentially , vital structures permitting. Mandibular resection: Decisions regarding management of the mandible when tumour lies close to, abuts or invades the bone are critical. If there is evidence of infiltrative bone invasion, either segmental or rim resection of the involved mandible is required. Management of the neck: In patients with clinical and/or radiographic evidence of cervical metastases, treatment of the neck in the form of a therapeutic neck dissection is indicated (primary radiotherapy is less common). In patients with early-stage disease and in whom there is no clinical or radiographic evidence for cervical metastases, there is now strong evidence showing that patients who have an up-front or elective neck dissection have better overall and disease-specific survival relative to patients who have a ‘watch-and-wait’ policy and a therapeutic neck dissection only when a metastasis becomes apparent. SLNB can be utilised as a staging investigation to better guide the indications for a neck dissection in the setting of a small tumour where occult metastases may still be present Chemoradiation: Adjuvant therapy is given based on pathological features of the tumour. Radiotherapy is administered typically via external beam radiotherapy. In high-risk cases, chemotherapy (usually cisplatin-based) is included as a radiosensitiser within the adjuvant regime for suitably fit patients. High risk tumors (warranting adjuvant CRT): Lympho-vascular invasion, Extra-nodal extension (ENE), peri-neural invasion. Trials (RTOG) provided strong evidence for the use of concurrent cisplatin-based CRT in high-risk patients.</li><li>➤ The gold standard in Oral cavity SCC is resection with a 1 cm clinical margin circumferentially , vital structures permitting.</li><li>➤ gold standard in Oral cavity SCC is resection with a 1 cm clinical margin circumferentially</li><li>➤ Mandibular resection: Decisions regarding management of the mandible when tumour lies close to, abuts or invades the bone are critical. If there is evidence of infiltrative bone invasion, either segmental or rim resection of the involved mandible is required.</li><li>➤ Management of the neck: In patients with clinical and/or radiographic evidence of cervical metastases, treatment of the neck in the form of a therapeutic neck dissection is indicated (primary radiotherapy is less common). In patients with early-stage disease and in whom there is no clinical or radiographic evidence for cervical metastases, there is now strong evidence showing that patients who have an up-front or elective neck dissection have better overall and disease-specific survival relative to patients who have a ‘watch-and-wait’ policy and a therapeutic neck dissection only when a metastasis becomes apparent.</li><li>➤ In patients with early-stage disease and in whom there is no clinical or radiographic evidence for cervical metastases, there is now strong evidence showing that patients who have an up-front or elective neck dissection have better overall and disease-specific survival relative to patients who have a ‘watch-and-wait’ policy and a therapeutic neck dissection only when a metastasis becomes apparent.</li><li>➤ SLNB can be utilised as a staging investigation to better guide the indications for a neck dissection in the setting of a small tumour where occult metastases may still be present</li><li>➤ Chemoradiation: Adjuvant therapy is given based on pathological features of the tumour. Radiotherapy is administered typically via external beam radiotherapy. In high-risk cases, chemotherapy (usually cisplatin-based) is included as a radiosensitiser within the adjuvant regime for suitably fit patients.</li><li>➤ Chemoradiation:</li><li>➤ High risk tumors (warranting adjuvant CRT): Lympho-vascular invasion, Extra-nodal extension (ENE), peri-neural invasion.</li><li>➤ High risk tumors (warranting adjuvant CRT):</li><li>➤ Trials (RTOG) provided strong evidence for the use of concurrent cisplatin-based CRT in high-risk patients.</li><li>➤ Ref: Bailey and Love Short Practice of Surgery 28th edition page 774</li><li>➤ Ref:</li><li>➤ Bailey and Love Short Practice of Surgery 28th edition page 774</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these free flaps is commonly used for soft tissue reconstruction in head and neck cancers?", "options": [{"label": "A", "text": "PMMC", "correct": false}, {"label": "B", "text": "Radial forearm flap", "correct": true}, {"label": "C", "text": "Naso-labial flap", "correct": false}, {"label": "D", "text": "Temporalis flap", "correct": false}], "correct_answer": "B. Radial forearm flap", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. PMMC - PMMC (pectoralis major myocutaneous flap) is not a free flap . It is a pedicled flap commonly used for head and neck reconstruction.</li><li>• Option A. PMMC</li><li>• not a free flap</li><li>• pedicled flap</li><li>• Option C. Naso-labial flap - Naso-labial flap is not a free flap . It is a local flap , and its use is limited to nearby tissue transfer.</li><li>• Option C. Naso-labial flap</li><li>• not a free flap</li><li>• local flap</li><li>• Option D. Temporalis flap - The temporalis flap is also not a free flap . It is a local flap based on the temporalis muscle and is used for reconstruction in specific cases.</li><li>• Option D. Temporalis flap</li><li>• not a free flap</li><li>• local flap</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The commonly used free flap for soft tissue reconstruction in head and neck cancers is the B. Radial forearm flap . It is harvested from the forearm and provides reliable vascularized tissue for reconstruction.</li><li>➤ free flap for soft tissue reconstruction</li><li>➤ head and neck cancers</li><li>➤ B. Radial forearm flap</li><li>➤ PMMC, nasolabial and temporalis flaps are not free flaps . PMMC is pedicled while NL and temporalis are local flaps.</li><li>➤ PMMC, nasolabial and temporalis flaps are not free flaps</li><li>➤ A free flap is a portion of vascularised tissue harvested from a distant donor site and transferred to an area requiring reconstruction where its artery and vein are anastomosed locally, thereby providing an independent blood supply. Most tissue types, including skin, fascia, muscle, tendon and bone can be harvested. Therefore, within the oral cavity both bone and soft tissue can be replaced with similar tissue(s). Soft-tissue reconstruction: In oral cavity reconstruction, common soft-tissue flaps used include the radial forearm free flap (RFFF) and anterolateral thigh (ALT) flap . Composite reconstruction: The fibula is the most commonly used bone-containing (composite) flap globally (Free fibular flap-FFF) , while the iliac crest (DCIA), scapula (including tip of scapula) and composite RFFFs are also used.</li><li>➤ A free flap is a portion of vascularised tissue harvested from a distant donor site and transferred to an area requiring reconstruction where its artery and vein are anastomosed locally, thereby providing an independent blood supply. Most tissue types, including skin, fascia, muscle, tendon and bone can be harvested. Therefore, within the oral cavity both bone and soft tissue can be replaced with similar tissue(s).</li><li>➤ Soft-tissue reconstruction: In oral cavity reconstruction, common soft-tissue flaps used include the radial forearm free flap (RFFF) and anterolateral thigh (ALT) flap .</li><li>➤ Soft-tissue reconstruction:</li><li>➤ (RFFF)</li><li>➤ (ALT) flap</li><li>➤ Composite reconstruction: The fibula is the most commonly used bone-containing (composite) flap globally (Free fibular flap-FFF) , while the iliac crest (DCIA), scapula (including tip of scapula) and composite RFFFs are also used.</li><li>➤ Composite reconstruction:</li><li>➤ fibula is the most commonly used bone-containing (composite) flap globally (Free fibular flap-FFF)</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 823</li><li>➤ Ref:</li><li>➤ Bailey and Love, 28 th Ed. Pg 823</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of these structures are removed in MRND except?", "options": [{"label": "A", "text": "Tail of parotid", "correct": false}, {"label": "B", "text": "Level 1b nodes", "correct": false}, {"label": "C", "text": "Sternocleidomastoid muscle", "correct": true}, {"label": "D", "text": "Submandibular gland", "correct": false}], "correct_answer": "C. Sternocleidomastoid muscle", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Sternocleidomastoid muscle</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Tail of parotid - The tail of the parotid gland can be removed in Modified Radical Neck Dissection (MRND) as part of the en-bloc resection of lymph nodes and associated structures.</li><li>• Option A. Tail of parotid</li><li>• can be removed in Modified Radical Neck Dissection</li><li>• en-bloc resection of lymph nodes</li><li>• Option B. Level 1b nodes - Level 1b nodes are removed in MRND .</li><li>• Option B. Level 1b nodes</li><li>• removed in MRND</li><li>• Option D. Submandibular gland - The submandibular gland can be removed in MRND .</li><li>• Option D. Submandibular gland</li><li>• removed in MRND</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In Modified Radical Neck Dissection (MRND), the sternocleidomastoid muscle is typically preserved , and its removal is not a standard part of the procedure . The goal of MRND is to remove lymph nodes and associated structures while preserving certain important neck muscles and vessels to maintain neck function.</li><li>➤ Modified Radical Neck Dissection</li><li>➤ sternocleidomastoid muscle is typically</li><li>➤ preserved</li><li>➤ removal is not a standard part of the procedure</li><li>➤ MRND is to remove lymph nodes</li><li>➤ associated structures while preserving certain important neck muscles</li><li>➤ Types of neck dissection:</li><li>➤ Types of neck dissection:</li><li>➤ CLASSICAL RADICAL NECK DISSECTION (CRILE): The classic operation involves resection of the cervical lymphatics and lymph nodes (levels 1 to 5) and those structures closely associated: the internal jugular vein, the accessory nerve, the submandibular gland, tail of parotid and the sternocleidomastoid muscle. These structures are all removed en-bloc and in continuity with the primary disease if possible . MODIFIED RADICAL NECK DISSECTION: In selected cases, one or more of the three following structures are preserved: the accessory nerve, the sternocleidomastoid muscle or the internal jugular vein . Otherwise, all major lymph node groups and lymphatics are excised. Careful note should be made of whichever structures are preserved. SELECTIVE NECK DISSECTION: In this type of dissection, one or more of the major lymph node groups is preserved along with the sternocleidomastoid muscle, accessory nerve and internal jugular vein. In these circumstances, the exact groups of nodes excised must be documented.</li><li>➤ CLASSICAL RADICAL NECK DISSECTION (CRILE): The classic operation involves resection of the cervical lymphatics and lymph nodes (levels 1 to 5) and those structures closely associated: the internal jugular vein, the accessory nerve, the submandibular gland, tail of parotid and the sternocleidomastoid muscle. These structures are all removed en-bloc and in continuity with the primary disease if possible .</li><li>➤ CLASSICAL RADICAL NECK DISSECTION (CRILE):</li><li>➤ These structures are all removed en-bloc and in continuity with the primary disease if possible</li><li>➤ MODIFIED RADICAL NECK DISSECTION: In selected cases, one or more of the three following structures are preserved: the accessory nerve, the sternocleidomastoid muscle or the internal jugular vein . Otherwise, all major lymph node groups and lymphatics are excised. Careful note should be made of whichever structures are preserved.</li><li>➤ MODIFIED RADICAL NECK DISSECTION:</li><li>➤ one or more of the three following structures are preserved: the accessory nerve, the sternocleidomastoid muscle or the internal jugular vein</li><li>➤ SELECTIVE NECK DISSECTION: In this type of dissection, one or more of the major lymph node groups is preserved along with the sternocleidomastoid muscle, accessory nerve and internal jugular vein. In these circumstances, the exact groups of nodes excised must be documented.</li><li>➤ SELECTIVE NECK DISSECTION:</li><li>➤ one or more of the major lymph node groups is preserved</li><li>➤ Types of selective neck dissections:</li><li>➤ Types of selective neck dissections:</li><li>➤ Supra-omohyoid: Level 1 to 3 nodes removed Lateral : Level 2 to 4 nodes removed Postero-lateral: Level 2 to 5 nodes removed</li><li>➤ Supra-omohyoid: Level 1 to 3 nodes removed</li><li>➤ Supra-omohyoid:</li><li>➤ Lateral : Level 2 to 4 nodes removed</li><li>➤ Lateral</li><li>➤ Postero-lateral: Level 2 to 5 nodes removed</li><li>➤ Postero-lateral:</li><li>➤ Ref: Bailey and Love, 27 th Ed. Pg 758-759</li><li>➤ Ref: Bailey and Love, 27 th Ed. Pg 758-759</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 70-year-old patient presents with a midline tumour of the lower jaw involving the alveolar margin. He is edentulous. What is the treatment of choice?", "options": [{"label": "A", "text": "Hemi-mandibulectomy", "correct": false}, {"label": "B", "text": "Commando operation", "correct": false}, {"label": "C", "text": "Segmental mandibulectomy", "correct": true}, {"label": "D", "text": "Marginal mandibulectomy", "correct": false}], "correct_answer": "C. Segmental mandibulectomy", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Segmental mandibulectomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Hemi-mandibulectomy - Hemi-mandibulectomy involves the surgical removal of one lateral half of the mandible . It is typically performed for malignant growths involving either the alveolar ridge and the mandible or adjacent structures . This procedure is not the treatment of choice in this specific case.</li><li>• Option A. Hemi-mandibulectomy</li><li>• surgical removal of one lateral half of the mandible</li><li>• performed for malignant growths</li><li>• alveolar ridge</li><li>• mandible or adjacent structures</li><li>• Option B. Commando operation - The Commando operation involves total glossectomy, hemi-mandibulectomy, removal of the floor of the mouth, and radical lymph node dissection. It is indicated when carcinoma is fixed to the mandible with infiltration of the floor of the mouth. This is a more extensive procedure and not the treatment of choice in this case.</li><li>• Option B. Commando operation</li><li>• total glossectomy, hemi-mandibulectomy, removal of the floor of the mouth, and radical lymph node dissection.</li><li>• Option D. Marginal mandibulectomy - Marginal mandibulectomy is the partial excision of the upper part of the lower jaw in the vertical phase . It does not involve the complete removal of a mandibular segment, and continuity of the jaw is preserved. This is not the treatment of choice for a midline tumor involving the alveolar margin.</li><li>• Option D. Marginal mandibulectomy</li><li>• partial excision of the upper part of the lower jaw in the vertical phase</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In a 70-year-old patient with a midline tumor of the lower jaw involving the alveolar margin , the treatment of choice is Segmental mandibulectomy . This procedure involves the resection of the entire affected mandibular segment and is indicated in specific cases as described.</li><li>➤ midline tumor of the lower jaw</li><li>➤ alveolar margin</li><li>➤ Segmental mandibulectomy</li><li>➤ Segmental mandibulectomy: The entire segment of the mandible is resected . Leads to discontinuity in the lower jaw. Indications Fixation of the tumour on the occlusal surface of the lower jaw in an edentulous patient Tumour invasion in the lower jaw, mandible foramen or mental foramen Hemi-mandibulectomy is the surgical removal of one lateral half of the mandible Usually performed on malignant growths involving either alveolar ridge and the mandible or adjacent structures, including floor of mouth Commandos’ operation: Total glossectomy + hemi mandibulectomy + removal of floor of mouth + radical lymph node dissection . Indicated when carcinoma is fixed to the mandible with infiltration of the floor of mouth</li><li>➤ Segmental mandibulectomy: The entire segment of the mandible is resected . Leads to discontinuity in the lower jaw. Indications Fixation of the tumour on the occlusal surface of the lower jaw in an edentulous patient Tumour invasion in the lower jaw, mandible foramen or mental foramen</li><li>➤ Segmental mandibulectomy:</li><li>➤ entire segment of the mandible is resected</li><li>➤ Fixation of the tumour on the occlusal surface of the lower jaw in an edentulous patient Tumour invasion in the lower jaw, mandible foramen or mental foramen</li><li>➤ Fixation of the tumour on the occlusal surface of the lower jaw in an edentulous patient</li><li>➤ Tumour invasion in the lower jaw, mandible foramen or mental foramen</li><li>➤ Hemi-mandibulectomy is the surgical removal of one lateral half of the mandible Usually performed on malignant growths involving either alveolar ridge and the mandible or adjacent structures, including floor of mouth</li><li>➤ Hemi-mandibulectomy</li><li>➤ surgical removal of one lateral half of the mandible</li><li>➤ Commandos’ operation: Total glossectomy + hemi mandibulectomy + removal of floor of mouth + radical lymph node dissection . Indicated when carcinoma is fixed to the mandible with infiltration of the floor of mouth</li><li>➤ Commandos’ operation:</li><li>➤ Total glossectomy + hemi mandibulectomy + removal of floor of mouth + radical lymph node dissection</li><li>➤ Note: Total glossectomy is the removal of the tongue including the base of tongue.</li><li>➤ Note:</li><li>➤ Marginal mandibulectomy is the partial excision of the upper part of the lower jaw in the vertical phase . Inner cortex and part of the medullary canal below are removed Continuity of the jaw is preserved A rim resection is sometimes performed when a tumour lies close to but does not definitively invade the mandible, in order to achieve a satisfactory soft-tissue margin.</li><li>➤ Marginal mandibulectomy is the partial excision of the upper part of the lower jaw in the vertical phase . Inner cortex and part of the medullary canal below are removed Continuity of the jaw is preserved A rim resection is sometimes performed when a tumour lies close to but does not definitively invade the mandible, in order to achieve a satisfactory soft-tissue margin.</li><li>➤ Marginal mandibulectomy</li><li>➤ partial excision of the upper part of the lower jaw</li><li>➤ vertical phase</li><li>➤ Inner cortex and part of the medullary canal below are removed Continuity of the jaw is preserved A rim resection is sometimes performed when a tumour lies close to but does not definitively invade the mandible, in order to achieve a satisfactory soft-tissue margin.</li><li>➤ Inner cortex and part of the medullary canal below are removed</li><li>➤ Continuity of the jaw is preserved</li><li>➤ A rim resection is sometimes performed when a tumour lies close to but does not definitively invade the mandible, in order to achieve a satisfactory soft-tissue margin.</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 821, Cancer of the head and neck by Suen and Pyer 4th edition pages 293 294</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 821, Cancer of the head and neck by Suen and Pyer 4th edition pages 293 294</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "The LAHSAL system is used for denoting?", "options": [{"label": "A", "text": "Oro-facial clefts", "correct": true}, {"label": "B", "text": "Degrees of oral leukoplakia", "correct": false}, {"label": "C", "text": "Extent of neck nodal metastasis", "correct": false}, {"label": "D", "text": "Mouth opening in trismus", "correct": false}], "correct_answer": "A. Oro-facial clefts", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/picture3.jpg"], "explanation": "<p><strong>Ans. A) Oro-facial clefts</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. Degrees of oral leukoplakia - This is not the correct use of the LAHSAL system. Oral leukoplakia is typically classified based on its clinical and histopathological features , not using the LAHSAL system.</li><li>• Option B. Degrees of oral leukoplakia</li><li>• Oral leukoplakia is typically classified based on its clinical and histopathological features</li><li>• Option C. Extent of neck nodal metastasis - The LAHSAL system is not used to denote the extent of neck nodal metastasis. The TNM (Tumor, Node, Metastasis) staging system is commonly used for cancer staging, including neck nodal involvement.</li><li>• Option C. Extent of neck nodal metastasis</li><li>• not used to denote the extent of neck nodal metastasis.</li><li>• Option D. Mouth opening in trismus - The LAHSAL system is not used to denote mouth opening in trismus. Trismus refers to restricted mouth opening and is typically measured in millimeters .</li><li>• Option D. Mouth opening in trismus</li><li>• Trismus refers to restricted mouth opening</li><li>• measured in millimeters</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ The LAHSAL system is used for denoting the types of orofacial clefts . It provides a standardized classification system for cleft lip and palate anomalies .</li><li>➤ LAHSAL system</li><li>➤ types of orofacial clefts</li><li>➤ standardized classification system for cleft lip and palate anomalies</li><li>➤ LAHSAL nomenclature for Oro-facial clefts (left to right):</li><li>➤ LAHSAL nomenclature for Oro-facial clefts (left to right):</li><li>➤ The typical distribution of cleft types is:</li><li>➤ The typical distribution of cleft types is:</li><li>➤ Cleft lip alone: 15% Cleft lip and palate: 45% Isolated cleft palate: 40%</li><li>➤ Cleft lip alone: 15%</li><li>➤ Cleft lip and palate: 45%</li><li>➤ Cleft lip and palate: 45%</li><li>➤ Isolated cleft palate: 40%</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 741-746.</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 741-746.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "At what age is cleft of lip with anterior palate repaired?", "options": [{"label": "A", "text": "At birth", "correct": false}, {"label": "B", "text": "At 3-6 months", "correct": true}, {"label": "C", "text": "At 9-12 months", "correct": false}, {"label": "D", "text": "At 18-24 months", "correct": false}], "correct_answer": "B. At 3-6 months", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) At 3-6 months</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Timing of repair of oro-facial clefts:</li><li>• Timing of repair of oro-facial clefts:</li><li>• Cleft lip/nose and anterior palate repair is performed between 3 and 6 months of age</li><li>• Cleft lip/nose and anterior palate repair is performed between 3 and 6 months of age</li><li>• Cleft lip/nose and anterior palate repair</li><li>• between 3 and 6 months of age</li><li>• The anterior palate closure is achieved by using a single-layer mucosal fap from the vomer . The lip is closed using a variety of described techniques but most surgeons believe that the muscle repair is more important than the skin incision, hence the variation.</li><li>• anterior palate closure</li><li>• single-layer mucosal fap from the vomer</li><li>• Definitive cleft palate repair is carried out between 6 and 12 months.</li><li>• Definitive cleft palate repair is carried out between 6 and 12 months.</li><li>• Definitive cleft palate repair</li><li>• between 6 and 12 months.</li><li>• The most common surgical approach in cleft palate repair is the intravelar veloplasty (IVVP), in which incisions along the cleft edge provide access to the soft palate muscle. The levator muscles are dissected free (Figure 50.8) and sutured together in the midline to recreate a muscular sling.</li><li>• common surgical approach in cleft palate repair is the intravelar veloplasty</li><li>• Alveolar bone grafting: The lateral incisor tooth is commonly absent or diminutive but, if present and of normal morphology , the bone graft can be timed around the root development of this tooth (often described as early secondary grafting at age 5–7 years).</li><li>• Alveolar bone grafting: The lateral incisor tooth is commonly absent or diminutive but, if present and of normal morphology , the bone graft can be timed around the root development of this tooth (often described as early secondary grafting at age 5–7 years).</li><li>• Alveolar bone grafting:</li><li>• lateral incisor tooth</li><li>• absent or diminutive but, if present and of normal morphology</li><li>• bone graft can be timed around the root development of this tooth</li><li>• Ref: Bailey and Love, 28 th Ed. Pg 745.</li><li>• Ref:</li><li>• Bailey and Love, 28 th Ed. Pg 745.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 70 years old male presents to OPD with severe cachexia and dysphagia to solids. Endoscopy shows lumen occluding growth at mid esophagus. While he is being investigated, you start him on TPN. After one day, patient gets seizures and tetany. What likely abnormality is responsible for the above event?", "options": [{"label": "A", "text": "Mets to brain", "correct": false}, {"label": "B", "text": "Hyponatremia", "correct": false}, {"label": "C", "text": "Hypophosphatemia", "correct": true}, {"label": "D", "text": "Hyperglycemia", "correct": false}], "correct_answer": "C. Hypophosphatemia", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Hypophosphatemia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Mets to brain - While metastases to the brain can cause seizures , the acute onset of seizures and tetany after starting TPN suggests a metabolic cause rather than new brain metastases.</li><li>• Option A: Mets to brain -</li><li>• metastases to the brain can cause seizures</li><li>• acute onset of seizures and tetany after starting TPN</li><li>• metabolic cause</li><li>• Option B: Hyponatremia - Hyponatremia can cause seizures due to an osmotic imbalance across the neuronal membrane , but it is not typically associated with the acute onset of tetany.</li><li>• Option B: Hyponatremia -</li><li>• cause seizures due to an osmotic imbalance</li><li>• neuronal membrane</li><li>• Option D: Hyperglycemia - Hyperglycemia can result from TPN due to the high glucose content in the solution; however, it is less likely to cause acute seizures and tetany compared to electrolyte disturbances like hypophosphatemia.</li><li>• Option D: Hyperglycemia -</li><li>• result from TPN due to the high glucose content in the solution;</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The sudden onset of seizures and tetany in a patient who has just started on TPN is most likely due to hypophosphatemia, a key feature of refeeding syndrome , which requires careful management and monitoring of electrolyte levels during the initiation of nutrition in malnourished patients.</li><li>➤ sudden onset of seizures and tetany</li><li>➤ who has just started on TPN is most likely due to hypophosphatemia,</li><li>➤ refeeding syndrome</li><li>➤ careful management and monitoring of electrolyte levels</li><li>➤ Refeeding syndrome : One of the most significant metabolic complications of both parenteral and enteral feeding is refeeding syndrome . This occurs in the first days after feeding is commenced in patients who have been severely malnourished. The degree of risk is related to their BMI, amount and rate of unintentional weight loss, period of starvation and electrolyte levels. The main underlying pathological process is one of hypophosphatemia, resulting in fluid and electrolyte shifts between the intra and extracellular compartments. Presentation includes arrythmias, muscle weakness, respiratory or cardiac failure, oedema, lethargy or seizures; and at its most severe, the syndrome can be fatal. Laboratory tests will reveal low levels of phosphate, potassium, calcium and magnesium and a lactic acidosis. Nutritional support in this group of patients should be started at a maximum of 10 kcal/kg per day, aiming to increase levels slowly to meet full needs by 4–7 days. Liver dysfunction : Long-term use of parenteral nutrition is associated with derangement of liver function tests in at least 25% of patients . Fatty liver is a common complication. This is worse in children, and the degree can be reduced by modifying the parenteral nutrition solution, such as alternating the use of lipid-free parenteral nutrition solutions. A smaller percentage of patients may subsequently develop liver fibrosis and cirrhosis.</li><li>➤ Refeeding syndrome : One of the most significant metabolic complications of both parenteral and enteral feeding is refeeding syndrome . This occurs in the first days after feeding is commenced in patients who have been severely malnourished. The degree of risk is related to their BMI, amount and rate of unintentional weight loss, period of starvation and electrolyte levels. The main underlying pathological process is one of hypophosphatemia, resulting in fluid and electrolyte shifts between the intra and extracellular compartments. Presentation includes arrythmias, muscle weakness, respiratory or cardiac failure, oedema, lethargy or seizures; and at its most severe, the syndrome can be fatal. Laboratory tests will reveal low levels of phosphate, potassium, calcium and magnesium and a lactic acidosis. Nutritional support in this group of patients should be started at a maximum of 10 kcal/kg per day, aiming to increase levels slowly to meet full needs by 4–7 days.</li><li>➤ Refeeding syndrome</li><li>➤ significant metabolic complications of both parenteral and enteral feeding is refeeding syndrome</li><li>➤ Liver dysfunction : Long-term use of parenteral nutrition is associated with derangement of liver function tests in at least 25% of patients . Fatty liver is a common complication. This is worse in children, and the degree can be reduced by modifying the parenteral nutrition solution, such as alternating the use of lipid-free parenteral nutrition solutions. A smaller percentage of patients may subsequently develop liver fibrosis and cirrhosis.</li><li>➤ Liver dysfunction</li><li>➤ Long-term use of parenteral nutrition is associated with derangement of liver function tests in at least 25% of patients</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 339-340.</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 339-340.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the feeding technique using this tube?", "options": [{"label": "A", "text": "Naso-gastric", "correct": false}, {"label": "B", "text": "Naso-jejunal", "correct": false}, {"label": "C", "text": "Percutaneous gastrostomy", "correct": true}, {"label": "D", "text": "Surgical gastrostomy", "correct": false}], "correct_answer": "C. Percutaneous gastrostomy", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-105808.png"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-105919.png", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-110107.png"], "explanation": "<p><strong>Ans. C) Percutaneous endoscopic gastrostomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Naso-gastric - This method involves the insertion of a feeding tube through the nose and down into the stomach. The tube in the image does not resemble a typical nasogastric tube, which is usually much longer and without the external fixation device.</li><li>• Option A: Naso-gastric -</li><li>• insertion of a feeding tube through the nose and down into the stomach.</li><li>• Option B: Naso-jejunal - Naso-jejunal feeding also involves a tube that passes through the nose but goes beyond the stomach into the jejunum. This tube, like a nasogastric tube, is typically longer and would not have a fixation device as seen in the image.</li><li>• Option B: Naso-jejunal -</li><li>• involves a tube that passes through the nose but goes beyond the stomach into the jejunum.</li><li>• Option D: Surgical gastrostomy - Surgical gastrostomy involves creating an opening into the stomach through a surgical procedure. While a PEG tube can be used for surgical gastrostomy, the method of insertion is different, and PEG specifically refers to the endoscopic technique.</li><li>• Option D: Surgical gastrostomy -</li><li>• creating an opening into the stomach through a surgical procedure.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The feeding technique using the tube shown in the image is most likely percutaneous endoscopic gastrostomy (PEG), as indicated by the external bumper and the shorter length suitable for percutaneous insertion through the abdominal wall.</li><li>➤ feeding technique using the tube shown in the image is most likely percutaneous endoscopic gastrostomy</li><li>➤ external bumper and the shorter length</li><li>➤ percutaneous insertion</li><li>➤ abdominal wall.</li><li>➤ A PEG involves the insertion of the gastrostomy tube through the abdomen and stomach under vision via an endoscope , avoiding a surgical incision and a general anesthetic . The endoscopist is able to visualize a cannula entering the insufflated stomach via the anterior abdominal wall, through which a guidewire is passed. Then either the gastrostomy tube can be inserted through the anterior abdominal wall over the guidewire or the guidewire can be pulled out via the mouth and the tube secured to the guidewire, pulled down into the stomach and then pulled out through the abdominal wall. The stomach wall is pulled up to the anterior abdominal wall and held in place by a cuff, balloon or plastic bumper to minimise the risk of intraperitoneal leakage.</li><li>➤ A PEG involves the insertion of the gastrostomy tube through the abdomen and stomach under vision via an endoscope , avoiding a surgical incision and a general anesthetic . The endoscopist is able to visualize a cannula entering the insufflated stomach via the anterior abdominal wall, through which a guidewire is passed.</li><li>➤ PEG involves the insertion of the gastrostomy tube through the abdomen and stomach under vision via an endoscope</li><li>➤ surgical incision and a general anesthetic</li><li>➤ Then either the gastrostomy tube can be inserted through the anterior abdominal wall over the guidewire or the guidewire can be pulled out via the mouth and the tube secured to the guidewire, pulled down into the stomach and then pulled out through the abdominal wall.</li><li>➤ The stomach wall is pulled up to the anterior abdominal wall and held in place by a cuff, balloon or plastic bumper to minimise the risk of intraperitoneal leakage.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 336-337</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 336-337</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is a false statement about hemorrhage?", "options": [{"label": "A", "text": "Reactionary hemorrhage is due to dislodgement of clot", "correct": false}, {"label": "B", "text": "Reactionary hemorrhage occurs 24-48 hours after surgery", "correct": true}, {"label": "C", "text": "Secondary hemorrhage is seen due to pressure by drain", "correct": false}, {"label": "D", "text": "Secondary hemorrhage occurs 7-14 days after surgery", "correct": false}], "correct_answer": "B. Reactionary hemorrhage occurs 24-48 hours after surgery", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Reactionary hemorrhage occurs 24-48 hours after surgery</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Reactionary hemorrhage is due to dislodgement of clot - This statement is true . Reactionary hemorrhage occurs when a clot that initially formed at the site of a blood vessel injury becomes dislodged before the vessel has had time to heal properly.</li><li>• Option A: Reactionary hemorrhage is due to dislodgement of clot -</li><li>• true</li><li>• Option C: Secondary hemorrhage is seen due to pressure by drain - This statement is true. Secondary hemorrhage can be precipitated by factors such as pressure necrosis from a drain, infection, or sloughing off of a vessel wall, which typically occurs 7-14 days post-surgery.</li><li>• Option C: Secondary hemorrhage is seen due to pressure by drain -</li><li>• true.</li><li>• Option D: Secondary hemorrhage occurs 7-14 days after surgery - This statement is also true. Secondary hemorrhage usually occurs after the first week post-surgery, most commonly between 7-14 days, as a result of infection or a breakdown of the vessel wall.</li><li>• Option D: Secondary hemorrhage occurs 7-14 days after surgery -</li><li>• true.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Reactionary hemorrhage is a delayed hemorrhage that occurs within the first 24 hours after surgery , usually due to dislodgement of a clot or slippage of a ligature , while secondary hemorrhage occurs 7-14 days’ post-surgery and is often related to infection or pressure necrosis .</li><li>➤ Reactionary hemorrhage is a delayed hemorrhage</li><li>➤ within the first 24 hours after surgery</li><li>➤ due to dislodgement of a clot or slippage of a ligature</li><li>➤ secondary hemorrhage occurs 7-14 days’ post-surgery</li><li>➤ infection or pressure necrosis</li><li>➤ Primary hemorrhage is a type of hemorrhage occurring immediately as a result of an injury (or surgery). Reactionary hemorrhage is delayed hemorrhage (within 24 hours) and is usually due to dislodgement of a clot by resuscitation , normalisation of blood pressure and vasodilatation. Reactionary hemorrhage may also be due to technical failure, such as slippage of a ligature. Secondary hemorrhage is due to sloughing of the wall of a vessel . It usually occurs 7–14 days after injury and is precipitated by factors such as infection, pressure necrosis (such as from a drain) or malignancy.</li><li>➤ Primary hemorrhage is a type of hemorrhage occurring immediately as a result of an injury (or surgery).</li><li>➤ Primary hemorrhage</li><li>➤ hemorrhage occurring immediately as a result of an injury</li><li>➤ Reactionary hemorrhage is delayed hemorrhage (within 24 hours) and is usually due to dislodgement of a clot by resuscitation , normalisation of blood pressure and vasodilatation. Reactionary hemorrhage may also be due to technical failure, such as slippage of a ligature.</li><li>➤ Reactionary hemorrhage</li><li>➤ delayed hemorrhage</li><li>➤ dislodgement of a clot by resuscitation</li><li>➤ Secondary hemorrhage is due to sloughing of the wall of a vessel . It usually occurs 7–14 days after injury and is precipitated by factors such as infection, pressure necrosis (such as from a drain) or malignancy.</li><li>➤ Secondary hemorrhage</li><li>➤ sloughing of the wall of a vessel</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 15</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 15</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 56 years old man got into a road traffic accident (RTA) and was brought to the casualty. After complete examination, it was found that he had lost 25% of his total blood volume approximately and blood pressure was normal. He will be classified under which class of hypovolemic shock?", "options": [{"label": "A", "text": "I", "correct": false}, {"label": "B", "text": "II", "correct": true}, {"label": "C", "text": "III", "correct": false}, {"label": "D", "text": "IV", "correct": false}], "correct_answer": "B. II", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-105010.png"], "explanation": "<p><strong>Ans. B) II</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 20-year-old girl presents to the casualty with 3-day history of nausea, anorexia, weakness, abdominal pain, and 5 episodes of vomiting associated with loose stools. She has no history of fever or respiratory or urinary symptoms. On examination, BP is 100/60 mm hg and HR is 130 beats per minute. On physical examination – she is thin built, with sunken eyes and slightly dry mucous membranes. Fluid resuscitation is started. What is the best guide for managing fluid resuscitation?", "options": [{"label": "A", "text": "Central Venous Pressure (CVP)", "correct": false}, {"label": "B", "text": "Urine output", "correct": true}, {"label": "C", "text": "BP", "correct": false}, {"label": "D", "text": "SpO 2", "correct": false}], "correct_answer": "B. Urine output", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Urine output</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: CVP - Central Venous Pressure (CVP) is an indicator of right atrial pressure and can be used to assess cardiac preload and volume status . While it can guide fluid resuscitation , it is invasive and not always the best initial guide .</li><li>• Option A: CVP - Central Venous Pressure</li><li>• indicator of right atrial pressure</li><li>• can be used to assess cardiac preload and volume status</li><li>• guide fluid resuscitation</li><li>• invasive and not always the best initial guide</li><li>• Option C: BP - Blood pressure is a vital sign that can indicate the efficacy of fluid resuscitation . However, BP alone may not accurately reflect the patient's hydration status, as it can be maintained near normal until late in the course of hypovolemia.</li><li>• Option C: BP -</li><li>• Blood pressure</li><li>• vital sign that can indicate the efficacy of fluid resuscitation</li><li>• Option D: SpO2 - Oxygen saturation (SpO2) indicates the level of oxygen in the blood and is not a direct measure of volume status or adequacy of fluid resuscitation.</li><li>• Option D: SpO2 -</li><li>• Oxygen saturation</li><li>• level of oxygen in the blood</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Urine output is the best non-invasive guide for managing fluid resuscitation in a patient with moderate dehydration due to acute gastroenteritis , as it provides immediate feedback on renal perfusion and organ perfusion.</li><li>➤ Urine output</li><li>➤ best non-invasive guide</li><li>➤ managing fluid resuscitation in a patient with moderate dehydration due to acute gastroenteritis</li><li>➤ Ultimately, the goal of treatment is to restore cellular and organ perfusion . Ideally, therefore, monitoring of organ perfusion should guide the management of shock. The best measure of organ perfusion and the best monitor of the adequacy of shock therapy remains the urine output. However, this is an hourly measure and does not give a minute-to-minute view of the shocked state. Currently, the only clinical indicators of perfusion of the gastrointestinal tract and muscular beds are the global measures of lactic acidosis (lactate and base deficit) and the mixed venous oxygen saturation.</li><li>➤ Ultimately, the goal of treatment is to restore cellular and organ perfusion . Ideally, therefore, monitoring of organ perfusion should guide the management of shock. The best measure of organ perfusion and the best monitor of the adequacy of shock therapy remains the urine output. However, this is an hourly measure and does not give a minute-to-minute view of the shocked state.</li><li>➤ goal of treatment is to restore cellular and organ perfusion</li><li>➤ Currently, the only clinical indicators of perfusion of the gastrointestinal tract and muscular beds are the global measures of lactic acidosis (lactate and base deficit) and the mixed venous oxygen saturation.</li><li>➤ Ref : Bailey and Love, 28 th Ed. page 19</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. page 19</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of these are seen in end stage of hemorrhagic shock except?", "options": [{"label": "A", "text": "Elevated fibrinogen", "correct": true}, {"label": "B", "text": "Platelet dysfunction", "correct": false}, {"label": "C", "text": "Hypothermia", "correct": false}, {"label": "D", "text": "Elevated lactates", "correct": false}], "correct_answer": "A. Elevated fibrinogen", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-105227.png"], "explanation": "<p><strong>Ans. A) Elevated fibrinogen</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Platelet dysfunction - Platelet dysfunction is seen in hemorrhagic shock due to multiple factors including consumption , dilution from fluid resuscitation, and the effects of acidosis.</li><li>• Option B: Platelet dysfunction -</li><li>• hemorrhagic shock due to multiple factors including consumption</li><li>• Option C: Hypothermia - Hypothermia is a common complication in hemorrhagic shock due to under-perfusion , exposure during surgery, and infusion of cold fluids or blood products.</li><li>• Option C: Hypothermia -</li><li>• common complication in hemorrhagic shock</li><li>• under-perfusion</li><li>• Option D: Elevated lactates - Elevated lactates are seen in hemorrhagic shock as a result of tissue hypoperfusion and anaerobic metabolism .</li><li>• Option D: Elevated lactates -</li><li>• hemorrhagic shock as a result of tissue hypoperfusion and anaerobic metabolism</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In the end stages of hemorrhagic shock, fibrinogen levels are typically low , not elevated , due to consumption and hyperfibrinolysis . Recognition and correction of coagulopathy, hypothermia, and acidosis are critical components of managing severe hemorrhagic shock.</li><li>➤ end stages of hemorrhagic shock, fibrinogen levels are typically low</li><li>➤ not elevated</li><li>➤ consumption and hyperfibrinolysis</li><li>➤ In trauma and surgery , the combination of tissue trauma and hypovolemic shock leads to the development of an endogenous coagulopathy called acute traumatic coagulopathy (ATC). Up to 25% of all trauma patients develop ATC within minutes of injury and it is associated with a fourfold increase in mortality. ATC is characterized by systemic hyperfibrinolysis, low fibrinogen levels and platelet dysfunction . ATC evolves into a more complex, multifactorial ‘trauma induced coagulopathy’ owing to further derangements induced by resuscitation. Fluid and red blood cell transfusions lead to dilution of coagulation factors, which worsens the pre-existing coagulopathy. Under-perfused muscle is unable to generate heat and hypothermia ensues, again worsened by cold fluid or blood transfusion. Further heat is lost by opening body cavities during surgery. Severe acidosis and hypothermia both inhibit coagulation proteases and reduce coagulation function. These then lead to further bleeding and a downward spiral, leading to physiological exhaustion and death.</li><li>➤ In trauma and surgery , the combination of tissue trauma and hypovolemic shock leads to the development of an endogenous coagulopathy called acute traumatic coagulopathy (ATC). Up to 25% of all trauma patients develop ATC within minutes of injury and it is associated with a fourfold increase in mortality.</li><li>➤ trauma and surgery</li><li>➤ combination of tissue trauma and hypovolemic shock leads to the development of an endogenous coagulopathy called acute traumatic coagulopathy</li><li>➤ ATC is characterized by systemic hyperfibrinolysis, low fibrinogen levels and platelet dysfunction . ATC evolves into a more complex, multifactorial ‘trauma induced coagulopathy’ owing to further derangements induced by resuscitation.</li><li>➤ ATC</li><li>➤ systemic hyperfibrinolysis, low fibrinogen levels and platelet dysfunction</li><li>➤ Fluid and red blood cell transfusions lead to dilution of coagulation factors, which worsens the pre-existing coagulopathy.</li><li>➤ Under-perfused muscle is unable to generate heat and hypothermia ensues, again worsened by cold fluid or blood transfusion.</li><li>➤ Under-perfused muscle</li><li>➤ unable to generate heat and hypothermia</li><li>➤ Further heat is lost by opening body cavities during surgery. Severe acidosis and hypothermia both inhibit coagulation proteases and reduce coagulation function. These then lead to further bleeding and a downward spiral, leading to physiological exhaustion and death.</li><li>➤ LETHAL TRIAD</li><li>➤ LETHAL TRIAD</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 14-15.</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 14-15.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these intra-venous therapies is preferred while performing damage control resuscitation in traumatic hemorrhage?", "options": [{"label": "A", "text": "Ringer’s Lactate", "correct": false}, {"label": "B", "text": "Normal Saline", "correct": false}, {"label": "C", "text": "Colloids", "correct": false}, {"label": "D", "text": "Blood products", "correct": true}], "correct_answer": "D. Blood products", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Blood products</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Ringer’s Lactate - Ringer's Lactate is a crystalloid solution used for fluid resuscitation . While it can be used in the initial management of hemorrhagic shock , it does not contain clotting factors or carry oxygen and can lead to dilutional coagulopathy if used excessively.</li><li>• Option A: Ringer’s Lactate -</li><li>• crystalloid solution used for fluid resuscitation</li><li>• initial management of hemorrhagic shock</li><li>• not contain clotting factors</li><li>• Option B: Normal Saline - Normal Saline is another crystalloid solution . Similar to Ringer’s Lactate, it can be used for initial volume expansion but is associated with hyperchloremic acidosis and does not contain blood clotting factors or oxygen-carrying capacity.</li><li>• Option B: Normal Saline -</li><li>• crystalloid solution</li><li>• used for initial volume expansion but is associated with hyperchloremic acidosis</li><li>• Option C: Colloids - Colloids, such as hydroxyethyl starch, are sometimes used for volume expansion, but they can interfere with hemostasis and do not provide oxygen-carrying capacity or clotting factors.</li><li>• Option C: Colloids -</li><li>• hydroxyethyl starch,</li><li>• used for volume expansion,</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ During damage control resuscitation in traumatic hemorrhage , the preferred intravenous therapy is blood products , as they help maintain hemostasis, oxygenation, and coagulation without causing dilutional coagulopathy.</li><li>➤ During damage control resuscitation</li><li>➤ traumatic hemorrhage</li><li>➤ intravenous therapy is blood products</li><li>➤ help maintain hemostasis, oxygenation, and coagulation</li><li>➤ without causing dilutional coagulopathy.</li><li>➤ DCR (Damage Control Resuscitation) applies only while patients are bleeding and is based on four key principles –</li><li>➤ DCR</li><li>➤ applies only while patients are bleeding</li><li>➤ Rapid hemorrhage control Permissive hypotension Avoiding dilutional coagulopathy Treating existing coagulation deficits.</li><li>➤ Rapid hemorrhage control</li><li>➤ Permissive hypotension</li><li>➤ Avoiding dilutional coagulopathy</li><li>➤ Treating existing coagulation deficits.</li><li>➤ Permissive hypotension : Permissive hypotension allows the patient to set their own blood pressure while bleeding and avoids continued volume resuscitation in the vain attempt to normalise perfusion while bleeding. This reduces blood loss from bleeding sites and reduces dilutional coagulopathy and hypothermia induced by fluids.</li><li>➤ Permissive hypotension</li><li>➤ patient to set their own blood pressure while bleeding and avoids continued volume resuscitation in the vain</li><li>➤ normalise perfusion while bleeding.</li><li>➤ It is important to maintain baseline perfusion of the coronary arteries at minimum, and thus a (mean arterial pressure above 50 mmHg) must be maintained by whatever means are available.</li><li>➤ maintain baseline perfusion of the coronary arteries at minimum,</li><li>➤ Avoid dilutional coagulopathy: Avoid dilutional coagulopathy by avoiding clear fluids (crystalloids or colloids) and by giving a transfusion that approximates whole blood.</li><li>➤ Usually administered as equal volumes of packed red blood cells and plasma and platelets (1:1:1).</li><li>➤ Treat existing coagulation deficits: Treat existing coagulopathies either empirically or by regular coagulation tests and acting on the results. Tranexamic acid should be given as soon as possible in almost all bleeding patients to stop hyperfibrinolysis.</li><li>➤ Treat existing coagulation deficits:</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 17</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 17</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "The length of Nasogastric tube insertion is calculated from?", "options": [{"label": "A", "text": "Upper incisors to ear lobule to xiphoid", "correct": false}, {"label": "B", "text": "Nose to ear lobule to xiphoid", "correct": true}, {"label": "C", "text": "Upper incisors to ear lobule to umbilicus", "correct": false}, {"label": "D", "text": "Nose to ear lobule to umbilicus", "correct": false}], "correct_answer": "B. Nose to ear lobule to xiphoid", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Nose to ear lobule to xiphoid</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The length of nasogastric tube insertion is calculated using the NEX rule , which measures from the nose to the earlobe and then to the xiphoid process to ensure proper placement in the stomach .</li><li>➤ length of nasogastric tube insertion is calculated using the NEX rule</li><li>➤ measures from the nose to the earlobe and then to the xiphoid process</li><li>➤ proper placement in the stomach</li><li>➤ Nasogastric tubes can usually be inserted in the ward setting . However, in patients in whom there may be any concerns regarding the oropharyngeal or esophago-gastric anatomy, endoscopic insertion under direct visualisation may be needed. Patients are positioned in a semi-recumbent position and the distance between the xiphisternum and the tip of the nose measured (NEX rule- Nose to ear lobule to xiphoid). The tube is inserted into the chosen nostril and advanced gently to the 10-cm point . Patients are then encouraged to swallow and the tube simultaneously advanced down the oesophagus with successive swallows until the distance measured to the xiphisternum is reached. Feed can also be delivered directly to the jejunum via either tube feeding or surgically created jejunostomies. The advantage of this is that it bypasses the stomach and can thus overcome problems of delayed gastric emptying without necessitating the use of total parenteral nutrition (TPN). Naso-jejunal feeding can also be used in patients who are unable to have a gastrostomy as this is the least invasive form of nutrient delivery into the jejunum. The siting of naso-jejunal tubes requires either endoscopic or radiological (fluoroscopic) guidance . Therefore, unlike nasogastric tubes, these cannot be inserted in the typical ward setting</li><li>➤ Nasogastric tubes can usually be inserted in the ward setting . However, in patients in whom there may be any concerns regarding the oropharyngeal or esophago-gastric anatomy, endoscopic insertion under direct visualisation may be needed.</li><li>➤ Nasogastric tubes can usually be inserted in the ward setting</li><li>➤ Patients are positioned in a semi-recumbent position and the distance between the xiphisternum and the tip of the nose measured (NEX rule- Nose to ear lobule to xiphoid).</li><li>➤ Patients are positioned in a semi-recumbent position and the distance between the xiphisternum and the tip of the nose measured</li><li>➤ The tube is inserted into the chosen nostril and advanced gently to the 10-cm point . Patients are then encouraged to swallow and the tube simultaneously advanced down the oesophagus with successive swallows until the distance measured to the xiphisternum is reached.</li><li>➤ tube is inserted into the chosen nostril and advanced gently to the 10-cm point</li><li>➤ Feed can also be delivered directly to the jejunum via either tube feeding or surgically created jejunostomies. The advantage of this is that it bypasses the stomach and can thus overcome problems of delayed gastric emptying without necessitating the use of total parenteral nutrition (TPN). Naso-jejunal feeding can also be used in patients who are unable to have a gastrostomy as this is the least invasive form of nutrient delivery into the jejunum.</li><li>➤ Feed can also be delivered directly to the jejunum via either tube feeding or surgically created jejunostomies.</li><li>➤ The siting of naso-jejunal tubes requires either endoscopic or radiological (fluoroscopic) guidance . Therefore, unlike nasogastric tubes, these cannot be inserted in the typical ward setting</li><li>➤ The siting of naso-jejunal tubes requires either endoscopic or radiological</li><li>➤ guidance</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 336</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 336</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of these are complications related to tube feeds except?", "options": [{"label": "A", "text": "Re-feeding syndrome", "correct": false}, {"label": "B", "text": "Diarrhoea", "correct": false}, {"label": "C", "text": "Electrolyte disturbances", "correct": false}, {"label": "D", "text": "Pneumothorax", "correct": true}], "correct_answer": "D. Pneumothorax", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Pneumothorax</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Re-feeding syndrome - Re-feeding syndrome can occur when feeding is initiated in malnourished patients , leading to rapid shifts in electrolytes as insulin secretion is stimulated . This is a recognized complication of enteral feeding, though it is more common in TPN.</li><li>• Option A: Re-feeding syndrome -</li><li>• occur when feeding is initiated in malnourished patients</li><li>• leading to rapid shifts in electrolytes as insulin secretion is stimulated</li><li>• Option B: Diarrhoea - Diarrhoea is a common complication of enteral feeding , possibly due to the osmolality of the feed, contamination, or the rapid delivery of feed into the small intestine.</li><li>• Option B: Diarrhoea -</li><li>• common complication of enteral feeding</li><li>• Option C: Electrolyte disturbances - Electrolyte disturbances can occur with enteral feeding, especially if the patient has underlying issues with fluid balance or if the feed composition does not match the patient's requirements.</li><li>• Option C: Electrolyte disturbances -</li><li>• occur with enteral feeding, especially if the patient has underlying issues</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ While re-feeding syndrome , diarrhoea, and electrolyte disturbances are complications associated with enteral feeding, pneumothorax is not ; it is instead related to central venous catheter insertion for total parenteral nutrition .</li><li>➤ re-feeding syndrome</li><li>➤ diarrhoea, and electrolyte disturbances are complications associated with enteral feeding, pneumothorax is not</li><li>➤ central venous catheter insertion for total parenteral nutrition</li><li>➤ Complications of enteral feeding:</li><li>➤ Tube related</li><li>➤ Tube related</li><li>➤ Tube related</li><li>➤ Malposition Displacement Blockage Breakage/leakage</li><li>➤ Malposition</li><li>➤ Displacement</li><li>➤ Blockage</li><li>➤ Breakage/leakage</li><li>➤ Local complications (e.g., erosion of skin/mucosa)</li><li>➤ Local complications (e.g., erosion of skin/mucosa)</li><li>➤ Local complications</li><li>➤ Gastrointestinal Diarrhoea Bloating, nausea, vomiting Abdominal cramps Aspiration Constipation</li><li>➤ Gastrointestinal</li><li>➤ Diarrhoea</li><li>➤ Bloating, nausea, vomiting</li><li>➤ Abdominal cramps</li><li>➤ Aspiration</li><li>➤ Constipation</li><li>➤ Metabolic/biochemical</li><li>➤ Metabolic/biochemical</li><li>➤ Metabolic/biochemical</li><li>➤ Electrolyte disorders, including refeeding syndrome Vitamin, mineral, trace element deficiencies Drug interactions</li><li>➤ Electrolyte disorders, including refeeding syndrome</li><li>➤ Vitamin, mineral, trace element deficiencies</li><li>➤ Drug interactions</li><li>➤ Pneumothorax is related with central venous catheter insertion done for giving Total Para-enteral Nutrition (TPN).</li><li>➤ Ref : Bailey and Love, 28 th Ed. Box 25.3</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Box 25.3</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the incorrect statement about total para-enteral nutrition (TPN)?", "options": [{"label": "A", "text": "Femoral lines should be avoided for parenteral nutrition because of the high risk of infections.", "correct": false}, {"label": "B", "text": "In patients who are likely to require long-term parenteral nutrition, an implantable port or a Hickman line may be more appropriate.", "correct": false}, {"label": "C", "text": "The line is considered to be in the correct place if the tip is in the inferior third of the SVC or at the atriocaval junction.", "correct": false}, {"label": "D", "text": "Most common indication for TPN is acute pancreatitis.", "correct": true}], "correct_answer": "D. Most common indication for TPN is acute pancreatitis.", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/untitled-600.jpg"], "explanation": "<p><strong>Ans. D) Most common indication for TPN is acute pancreatitis.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Femoral lines should be avoided for parenteral nutrition because of the high risk of infections . - This statement is true . Femoral lines do carry a higher risk of infection and are generally avoided for TPN unless there are no other options.</li><li>• Option A:</li><li>• Femoral lines should be avoided for parenteral nutrition because of the high risk of infections</li><li>• -</li><li>• true</li><li>• Option B: In patients who are likely to require long-term parenteral nutrition, an implantable port or a Hickman line may be more appropriate . - This statement is also true . For long-term TPN, more permanent and less infection-prone access such as an implantable port or Hickman line is preferred.</li><li>• Option B:</li><li>• In patients who are likely to require long-term parenteral nutrition, an implantable port or a Hickman line may be more appropriate</li><li>• -</li><li>• true</li><li>• Option C: The line is considered to be in the correct place if the tip is in the inferior third of the SVC or at the atriocaval junction . - This statement is true . The tip of the central line for TPN should ideally be located at the inferior third of the superior vena cava (SVC) or at the cavoatrial junction to ensure proper infusion and minimize risks.</li><li>• Option C:</li><li>• The line is considered to be in the correct place if the tip is in the inferior third of the SVC or at the atriocaval junction</li><li>• -</li><li>• true</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most common indication for TPN is not acute pancreatitis , but conditions causing a significant reduction in the functional small bowel , often related to massive intestinal resection or fistulation . Proper line placement and avoiding high-infection-risk access points are crucial for the safe administration of TPN.</li><li>➤ common indication for TPN is not acute pancreatitis</li><li>➤ conditions causing a significant reduction in the functional small bowel</li><li>➤ massive intestinal resection or fistulation</li><li>➤ TPN is indicated in patients who are unable to meet their nutritional requirements via absorption of nutrients from their intestinal tract. The commonest cause for this is in patients with short bowel syndrome related to massive intestinal resection or a significant reduction in functional small bowel, often related to intestinal fistulation. Commonly provided by the hospital pharmacy in the form of a 3-litre bag containing a lipid emulsion with a mixture of essential and non-essential amino acids, glucose, electrolytes, trace elements and vitamins. Usually administered directly into the central venous system (the superior vena cava [SVC] or the right atrium) to minimise the risk of venous thrombophlebitis, through either a peripherally inserted central catheter (PICC) or central venous catheter. Femoral lines should be avoided for parenteral nutrition because of the high risk of infection. In patients who are likely to require long-term parenteral nutrition, an implantable port or a Hickman line may be more appropriate. These are implanted via fluoroscopic or ultrasound guidance with a subcutaneous port or cuff and a catheter attachment sitting within the SVC. Line misplacement can also occur and is diagnosed on chest radiograph, which is mandatory following central line insertion. The line is considered to be in the correct place if the tip is in the inferior third of the SVC or at the atriocaval junction.</li><li>➤ TPN is indicated in patients who are unable to meet their nutritional requirements via absorption of nutrients from their intestinal tract.</li><li>➤ TPN is indicated in patients who are unable to meet their nutritional requirements</li><li>➤ The commonest cause for this is in patients with short bowel syndrome related to massive intestinal resection or a significant reduction in functional small bowel, often related to intestinal fistulation.</li><li>➤ Commonly provided by the hospital pharmacy in the form of a 3-litre bag containing a lipid emulsion with a mixture of essential and non-essential amino acids, glucose, electrolytes, trace elements and vitamins.</li><li>➤ Usually administered directly into the central venous system (the superior vena cava [SVC] or the right atrium) to minimise the risk of venous thrombophlebitis, through either a peripherally inserted central catheter (PICC) or central venous catheter.</li><li>➤ Usually administered directly into the central venous system</li><li>➤ minimise the risk of venous thrombophlebitis,</li><li>➤ Femoral lines should be avoided for parenteral nutrition because of the high risk of infection.</li><li>➤ In patients who are likely to require long-term parenteral nutrition, an implantable port or a Hickman line may be more appropriate. These are implanted via fluoroscopic or ultrasound guidance with a subcutaneous port or cuff and a catheter attachment sitting within the SVC.</li><li>➤ Line misplacement can also occur and is diagnosed on chest radiograph, which is mandatory following central line insertion. The line is considered to be in the correct place if the tip is in the inferior third of the SVC or at the atriocaval junction.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 338-339</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 338-339</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is the most common complication of TPN during inserting of central venous catheter?", "options": [{"label": "A", "text": "Air embolism", "correct": false}, {"label": "B", "text": "Pneumothorax", "correct": true}, {"label": "C", "text": "Thrombophlebitis", "correct": false}, {"label": "D", "text": "Arterial cannulation", "correct": false}], "correct_answer": "B. Pneumothorax", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Pneumothorax</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of the following patients are at an increased risk of refeeding syndrome except?", "options": [{"label": "A", "text": "BMI &lt;16 kg/sq.m", "correct": false}, {"label": "B", "text": "Unintentional weight loss &gt; 15% in 3 to 6 months", "correct": false}, {"label": "C", "text": "Starvation &gt; 10 days", "correct": false}, {"label": "D", "text": "Elevated magnesium levels", "correct": true}], "correct_answer": "D. Elevated magnesium levels", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Elevated magnesium levels</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Patient is considered to be at risk of developing refeeding syndrome with EITHER One or more of the following:</li><li>• Patient is considered to be at risk of developing refeeding syndrome with EITHER One or more of the following:</li><li>• BMI &lt;16 Unintentional weight loss &gt; 15% within the last 3–6 months Little or no nutritional intake for more than 10 days Low potassium, phosphate or magnesium levels prior to feeding</li><li>• BMI &lt;16</li><li>• Unintentional weight loss &gt; 15% within the last 3–6 months</li><li>• Little or no nutritional intake for more than 10 days</li><li>• Low potassium, phosphate or magnesium levels prior to feeding</li><li>• OR</li><li>• Two of more of the following:</li><li>• Two of more of the following:</li><li>• BMI &lt;18.5 Unintentional weight loss &gt; 10% within the last 3–6 months Little or no nutritional intake for more than 5 days History of alcohol abuse or on medication, including insulin, chemotherapy, antacids or diuretics</li><li>• BMI &lt;18.5</li><li>• Unintentional weight loss &gt; 10% within the last 3–6 months</li><li>• Little or no nutritional intake for more than 5 days</li><li>• History of alcohol abuse or on medication, including insulin, chemotherapy, antacids or diuretics</li><li>• Ref : Bailey and Love 28 th Ed. Pg 340, Box 25.5</li><li>• Ref</li><li>• : Bailey and Love 28 th Ed. Pg 340, Box 25.5</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In patients on artificial feeds, all of these parameters require daily monitoring in the initial periods except?", "options": [{"label": "A", "text": "Serum electrolytes", "correct": false}, {"label": "B", "text": "Body weight", "correct": false}, {"label": "C", "text": "Blood sugar levels", "correct": false}, {"label": "D", "text": "Serum triglycerides", "correct": true}], "correct_answer": "D. Serum triglycerides", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-111028.png"], "explanation": "<p><strong>Ans. D) Serum triglycerides</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In a degloving injury, which of the following components are stripped off?", "options": [{"label": "A", "text": "Skin", "correct": false}, {"label": "B", "text": "Skin + Superficial fascia", "correct": true}, {"label": "C", "text": "Skin, superficial and deep fascia", "correct": false}, {"label": "D", "text": "Skin, superficial, deep fascia and muscles", "correct": false}], "correct_answer": "B. Skin + Superficial fascia", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/untitled-609.jpg"], "explanation": "<p><strong>Ans. B) Skin + Superficial fascia</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Stage the pressure sore as shown in the picture below?", "options": [{"label": "A", "text": "Stage 1", "correct": false}, {"label": "B", "text": "Stage 2", "correct": true}, {"label": "C", "text": "Stage 3", "correct": false}, {"label": "D", "text": "Stage 4", "correct": false}], "correct_answer": "B. Stage 2", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/untitled-606.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/untitled-607.jpg"], "explanation": "<p><strong>Ans. B) Stage 2</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• The stage of the above pressure sore/ pressure ulcer is Stage 2 due to partial thickness loss of skin.</li><li>• partial thickness loss of skin.</li><li>• Ref : Bailey and Love, 28 th Ed. Pg 35</li><li>• Ref :</li><li>• Bailey and Love, 28 th Ed. Pg 35</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is not true regarding keloids and hypertrophic scars?", "options": [{"label": "A", "text": "Hypertrophic scars do not extend beyond the boundary of the original incision or wound and eventually regress.", "correct": false}, {"label": "B", "text": "Hypertrophic scars are more common in areas of increased tension", "correct": false}, {"label": "C", "text": "Keloid scars do not extend beyond the boundaries of the original incision or wound", "correct": true}, {"label": "D", "text": "Keloid scars often occur as a result of relatively minor trauma and mainly in those with darker skin pigmentation.", "correct": false}], "correct_answer": "C. Keloid scars do not extend beyond the boundaries of the original incision or wound", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Keloid scars do not extend beyond the boundaries of the original incision or wound</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A. Hypertrophic scars do not extend beyond the boundary of the original incision or wound and eventually regress . This statement is true . Hypertrophic scars are confined to the boundaries of the original wound and may regress over time.</li><li>• Option A.</li><li>• Hypertrophic scars do not extend beyond the boundary of the original incision or wound and eventually regress</li><li>• true</li><li>• Option B. Hypertrophic scars are more common in areas of increased tension . This statement is also true . Hypertrophic scars commonly develop in areas of the skin that are under increased tension.</li><li>• Option B.</li><li>• Hypertrophic scars are more common in areas of increased tension</li><li>• true</li><li>• Option D. Keloid scars often occur as a result of relatively minor trauma and mainly in those with darker skin pigmentation . This is true. Keloids can develop even after minor skin trauma and are more prevalent among individuals with darker skin tones.</li><li>• Option D.</li><li>• Keloid scars often occur as a result of relatively minor trauma and mainly in those with darker skin pigmentation</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Keloid scars are notable for extending beyond the boundaries of the original incision or wound and are not prone to spontaneous regression, distinguishing them from hypertrophic scars.</li><li>➤ Hypertrophic scars and keloids contain excess collagen, which is arranged in a disorganised pattern in keloid scars as opposed to a parallel pattern in hypertrophic scars. Hypertrophic scars do not extend beyond the boundary of the original incision or wound and eventually regress. They are more common in areas of increased tension, wounds crossing tension lines, deep dermal burns and wounds left to heal by secondary intention (longer than 3 weeks). Keloid scars extend beyond the boundaries of the original incision or wound, do not spontaneously regress and are difficult to treat. The aetiology is unknown but genetic predisposition is implicated. They often occur as a result of relatively minor trauma and mainly in those with darker skin pigmentation.</li><li>➤ Hypertrophic scars and keloids contain excess collagen, which is arranged in a disorganised pattern in keloid scars as opposed to a parallel pattern in hypertrophic scars.</li><li>➤ disorganised pattern in keloid scars</li><li>➤ parallel pattern in hypertrophic scars.</li><li>➤ Hypertrophic scars do not extend beyond the boundary of the original incision or wound and eventually regress. They are more common in areas of increased tension, wounds crossing tension lines, deep dermal burns and wounds left to heal by secondary intention (longer than 3 weeks).</li><li>➤ Hypertrophic scars</li><li>➤ more common in areas of increased tension, wounds crossing tension lines, deep dermal burns and wounds left to heal by secondary intention (longer than 3 weeks).</li><li>➤ Keloid scars extend beyond the boundaries of the original incision or wound, do not spontaneously regress and are difficult to treat. The aetiology is unknown but genetic predisposition is implicated. They often occur as a result of relatively minor trauma and mainly in those with darker skin pigmentation.</li><li>➤ Keloid scars</li><li>➤ extend beyond the boundaries of the original incision or wound,</li><li>➤ do not spontaneously regress</li><li>➤ genetic predisposition</li><li>➤ Ref: Bailey and Love’s short practice of surgery 28 th edition pg 28</li><li>➤ Ref:</li><li>➤ Bailey and Love’s short practice of surgery 28 th edition pg</li><li>➤ 28</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these factors do not affect wound healing?", "options": [{"label": "A", "text": "Malnutrition", "correct": false}, {"label": "B", "text": "Alcoholism", "correct": true}, {"label": "C", "text": "Diabetes mellitus", "correct": false}, {"label": "D", "text": "Infection", "correct": false}], "correct_answer": "B. Alcoholism", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Alcoholism</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Local and systemic factors influencing wound healing .</li><li>• Local and systemic</li><li>• influencing wound healing</li><li>• Local Skin tension Hypoxia and ischaemia Vascular insufficiency Lymphoedema Contamination Infection (Option D) Presence of foreign bodies Radiotherapy Systemic Advancing age Obesity Malnutrition (Option A) Smoking Diseases (e.g., diabetes mellitus, connective tissue diseases) (Option C) Immuno-compromised (e.g., acquired immunodeficiency syndrome) Medications (e.g., steroids, immunosuppressants)</li><li>• Local Skin tension Hypoxia and ischaemia Vascular insufficiency Lymphoedema Contamination Infection (Option D) Presence of foreign bodies Radiotherapy</li><li>• Local</li><li>• Skin tension Hypoxia and ischaemia Vascular insufficiency Lymphoedema Contamination Infection (Option D) Presence of foreign bodies Radiotherapy</li><li>• Skin tension</li><li>• Hypoxia and ischaemia</li><li>• Vascular insufficiency</li><li>• Lymphoedema</li><li>• Contamination</li><li>• Infection (Option D)</li><li>• Infection (Option D)</li><li>• Presence of foreign bodies</li><li>• Radiotherapy</li><li>• Systemic Advancing age Obesity Malnutrition (Option A) Smoking Diseases (e.g., diabetes mellitus, connective tissue diseases) (Option C) Immuno-compromised (e.g., acquired immunodeficiency syndrome) Medications (e.g., steroids, immunosuppressants)</li><li>• Systemic</li><li>• Advancing age Obesity Malnutrition (Option A) Smoking Diseases (e.g., diabetes mellitus, connective tissue diseases) (Option C) Immuno-compromised (e.g., acquired immunodeficiency syndrome) Medications (e.g., steroids, immunosuppressants)</li><li>• Advancing age</li><li>• Obesity</li><li>• Malnutrition (Option A)</li><li>• Malnutrition (Option A)</li><li>• Smoking</li><li>• Diseases (e.g., diabetes mellitus, connective tissue diseases) (Option C)</li><li>• Immuno-compromised (e.g., acquired immunodeficiency syndrome)</li><li>• Medications (e.g., steroids, immunosuppressants)</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Alcoholism is not a direct factor that affects wound healing.</li><li>➤ Ref: Bailey and Love’s short practice of surgery 28 th edition Pg 27</li><li>➤ Ref:</li><li>➤ Bailey and Love’s short practice of surgery 28 th edition Pg 27</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "What will be the initial treatment of the pathology in the image?", "options": [{"label": "A", "text": "Pulsed Laser therapy", "correct": false}, {"label": "B", "text": "5-FU cream", "correct": false}, {"label": "C", "text": "Intralesional steroids", "correct": true}, {"label": "D", "text": "Wide excision", "correct": false}], "correct_answer": "C. Intralesional steroids", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/untitled-602.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Intralesional steroids</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Pulsed Laser Therapy Pulsed dye laser therapy is used for the treatment of keloids and may help reduce redness and improve texture . However, it is not usually the initial treatment but rather a part of subsequent therapy.</li><li>• Option A. Pulsed Laser Therapy</li><li>• treatment of keloids and may help reduce redness and improve texture</li><li>• Option B. 5-FU Cream The application of 5-fluorouracil (5-FU) cream can be a part of keloid treatment, especially when used in conjunction with intralesional steroids . It is generally not the first line of treatment.</li><li>• Option B. 5-FU Cream</li><li>• part of keloid treatment, especially when used in conjunction with intralesional steroids</li><li>• Option D. Wide Excision Wide excision of keloids has a high recurrence rate and is typically reserved for cases that do not respond to other treatments. It is often combined with other modalities such as radiotherapy or pressure garments post-surgery.</li><li>• Option D. Wide Excision</li><li>• high recurrence rate and is typically reserved for cases that do not respond to other treatments.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The initial treatment for keloids , such as the one shown over the sternal triangle , is intralesional steroid injections , which can reduce the keloid size and symptoms . Subsequent treatments may include pulsed dye laser, 5-FU cream, or surgical options depending on the response and severity.</li><li>➤ initial treatment for keloids</li><li>➤ over the sternal triangle</li><li>➤ intralesional steroid injections</li><li>➤ reduce the keloid size and symptoms</li><li>➤ Management:</li><li>➤ Management:</li><li>➤ Minor/raised (red): Intralesional steroid + Silicon sheet/garment → pulsed dye laser → Intralesional excision + Radiotherapy/silicon sheets/Bleomycin Major/raised (dark): Intralesional steroid → 5FU + Intralesional steroid → Pulsed dye laser → Intralesional excision + Radiotherapy/silicon sheets/Bleomycin</li><li>➤ Minor/raised (red): Intralesional steroid + Silicon sheet/garment → pulsed dye laser → Intralesional excision + Radiotherapy/silicon sheets/Bleomycin</li><li>➤ Minor/raised (red):</li><li>➤ →</li><li>➤ →</li><li>➤ Major/raised (dark): Intralesional steroid → 5FU + Intralesional steroid → Pulsed dye laser → Intralesional excision + Radiotherapy/silicon sheets/Bleomycin</li><li>➤ Major/raised (dark):</li><li>➤ →</li><li>➤ →</li><li>➤ →</li><li>➤ Management of hypertrophic scar:</li><li>➤ Management of hypertrophic scar:</li><li>➤ Silicon sheets → Intralesional steroids → Pulsed dye lase → Excision</li><li>➤ Silicon sheets → Intralesional steroids</li><li>➤ →</li><li>➤ Pulsed dye lase → Excision</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 36-37.</li><li>➤ Ref :</li><li>➤ Bailey and Love, 28 th Ed. Pg 36-37.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following scoring systems is used for grading wound infections?", "options": [{"label": "A", "text": "Southampton score", "correct": true}, {"label": "B", "text": "Rutherford classification", "correct": false}, {"label": "C", "text": "CEAP classification", "correct": false}, {"label": "D", "text": "Glasgow score", "correct": false}], "correct_answer": "A. Southampton score", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/18/screenshot-2024-03-18-185730.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/18/screenshot-2024-03-18-185831.jpg"], "explanation": "<p><strong>Ans. A) Southampton score</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option B. Rutherford classification The Rutherford classification is used for grading peripheral arterial disease and is not used for grading wound infections.</li><li>• Option B. Rutherford classification</li><li>• grading peripheral arterial disease</li><li>• Option C. CEAP classification The CEAP classification is used to classify chronic venous insufficiency/varicose veins but not for grading wound infections.</li><li>• Option C. CEAP classification</li><li>• classify chronic venous insufficiency/varicose veins</li><li>• Option D. Glasgow score The Glasgow score, also known as the Glasgow Coma Scale, is used to assess the level of consciousness after a head injury and is not relevant to wound infections.</li><li>• Option D. Glasgow score</li><li>• used to assess the level of consciousness after a head injury</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Southampton score system is used for grading wound infections , evaluating the clinical signs and severity of an infection .</li><li>➤ Southampton score system</li><li>➤ grading wound infections</li><li>➤ clinical signs</li><li>➤ severity of an infection</li><li>➤ Southampton wound grading system</li><li>➤ Southampton wound grading system</li><li>➤ ASEPSIS WOUND SCORE:</li><li>➤ ASEPSIS WOUND SCORE:</li><li>➤ Ref : Online reference https://www.researchgate.net/publication/235729965_Perineal_reconstruction_after_extra-levator_abdominoperineal_excision_eLAPE_A_systematic_review</li><li>➤ Ref :</li><li>➤ Online reference</li><li>➤ https://www.researchgate.net/publication/235729965_Perineal_reconstruction_after_extra-levator_abdominoperineal_excision_eLAPE_A_systematic_review</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old uncontrolled diabetic comes with anterior abdominal wall necrotizing fasciitis as shown in the picture below. What could be the most common causative organism for the same?", "options": [{"label": "A", "text": "Polymicrobial", "correct": true}, {"label": "B", "text": "Clostridium", "correct": false}, {"label": "C", "text": "Staphylococcus aureus", "correct": false}, {"label": "D", "text": "Escherichia coli", "correct": false}], "correct_answer": "A. Polymicrobial", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/untitled-605.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. A) Polymicrobial</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option B. Clostridium While Clostridium species can cause necrotizing fasciitis , they are not the most common causative organisms , although they are implicated in gas gangrene, which can present with similar findings.</li><li>• Option B. Clostridium</li><li>• cause necrotizing fasciitis</li><li>• not the most common causative organisms</li><li>• Option C. Staphylococcus aureus Staphylococcus aureus can cause soft tissue infections but is less commonly associated with necrotizing fasciitis compared to polymicrobial infections in diabetic patients.</li><li>• Option C. Staphylococcus aureus</li><li>• cause soft tissue infections</li><li>• less commonly associated with necrotizing fasciitis</li><li>• Option D. Escherichia coli Escherichia coli is not typically the primary pathogen in necrotizing fasciitis but can be part of a polymicrobial infection . It is usually implicated in urinary and GIT infections.</li><li>• Option D. Escherichia coli</li><li>• not typically the primary pathogen in necrotizing fasciitis</li><li>• polymicrobial infection</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most common cause of necrotizing fasciitis in uncontrolled diabetics is a polymicrobial infection involving a mix of aerobic and anaerobic bacteria .</li><li>➤ cause of necrotizing fasciitis in uncontrolled diabetics</li><li>➤ polymicrobial infection</li><li>➤ mix of aerobic and anaerobic bacteria</li><li>➤ There is usually a history of trauma or surgery with wound contamination. Diabetes mellitus is the most common comorbidity.</li><li>➤ Diabetes mellitus is the most common comorbidity.</li><li>➤ Signs and symptoms of necrotising fasciitis:</li><li>➤ Signs and symptoms of necrotising fasciitis:</li><li>➤ Local - Unusual pain à Erythema, oedema, warmth, Crepitus, Blisters, bullae à Greyish drainage (dishwater pus) with Fixed staining à Necrosis, gangrene Systemic - Fever, tachycardia, tachypnoea à Shock and Coagulopathy à Multiorgan failure</li><li>➤ Local - Unusual pain à Erythema, oedema, warmth, Crepitus, Blisters, bullae à Greyish drainage (dishwater pus) with Fixed staining à Necrosis, gangrene</li><li>➤ (dishwater pus)</li><li>➤ Systemic - Fever, tachycardia, tachypnoea à Shock and Coagulopathy à Multiorgan failure</li><li>➤ Treatment:</li><li>➤ Treatment:</li><li>➤ Appropriate intravenous antibiotics with urgent radical surgical debridement . A second look operation is usually planned in 24–48 hours depending on clinical response. Multiple debridement may be required. Hyperbaric oxygen therapy may be beneficial.</li><li>➤ Appropriate intravenous antibiotics with urgent radical surgical debridement . A second look operation is usually planned in 24–48 hours depending on clinical response. Multiple debridement may be required.</li><li>➤ intravenous antibiotics</li><li>➤ urgent radical surgical debridement</li><li>➤ Hyperbaric oxygen therapy may be beneficial.</li><li>➤ Hyperbaric oxygen therapy</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 34</li><li>➤ Ref :</li><li>➤ Bailey and Love’s short practice of surgery 28 th edition pg 34</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A poorly controlled diabetic patient presented with the following picture. There was crepitus on palpation. All the following statements are true about this condition except:", "options": [{"label": "A", "text": "Occurs due to gradual slowing of blood flow and desiccation of tissues", "correct": true}, {"label": "B", "text": "Has superadded putrefaction", "correct": false}, {"label": "C", "text": "The black colour is due to iron sulphide formation from hemoglobin", "correct": false}, {"label": "D", "text": "Require urgent debridement / amputation", "correct": false}], "correct_answer": "A. Occurs due to gradual slowing of blood flow and desiccation of tissues", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/untitled-608.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. A)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. Has superadded putrefaction This is true for wet gangrene . The condition often involves infection with bacteria that can produce gas and putrefaction.</li><li>• Option B. Has superadded putrefaction</li><li>• true</li><li>• wet gangrene</li><li>• Option C. The black colour is due to iron sulphide formation from hemoglobin This statement is true and refers to the characteristic black colour of the gangrenous tissue due to the breakdown of hemoglobin and subsequent iron sulphide formation.</li><li>• Option C. The black colour is due to iron sulphide formation from hemoglobin</li><li>• true</li><li>• characteristic black colour of the gangrenous tissue due to the breakdown of hemoglobin</li><li>• Option D. Require urgent debridement / amputation This is also true . Wet gangrene is a surgical emergency and requires prompt intervention to remove the dead tissue and prevent further spread of the infection.</li><li>• Option D. Require urgent debridement / amputation</li><li>• true</li><li>• Wet gangrene is a surgical emergency</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Wet gangrene , often associated with infection in diabetic patients , requires immediate medical attention , contrasting with dry gangrene , which results from the slow desiccation of tissue due to impaired blood flow .</li><li>➤ Wet gangrene</li><li>➤ infection in diabetic patients</li><li>➤ immediate medical attention</li><li>➤ contrasting with dry gangrene</li><li>➤ slow desiccation of tissue due to impaired blood flow</li><li>➤ Gangrene refers to the death of macroscopic portions of tissue, which turns black because of the breakdown of haemoglobin and the formation of iron sulphide. It usually affects the most distal part of a limb because of arterial obstruction (from thrombosis, embolus or arteritis). 2 Types of gangrene occur:</li><li>➤ Gangrene refers to the death of macroscopic portions of tissue, which turns black because of the breakdown of haemoglobin and the formation of iron sulphide. It usually affects the most distal part of a limb because of arterial obstruction (from thrombosis, embolus or arteritis). 2 Types of gangrene occur:</li><li>➤ Dry gangrene occurs when the tissues are desiccated by gradual slowing of the blood stream ; it is typically the result of atheromatous occlusion of arteries. A clear line of demarcation if usually seen.</li><li>➤ Dry gangrene</li><li>➤ gradual slowing of the blood stream</li><li>➤ Wet gangrene occurs when superadded infection and putrefaction are present . Crepitus may be palpated as a result of infection by gas-forming organisms, commonly in diabetic foot problems, and should be considered a surgical emergency with urgent tissue debridement or amputation required.</li><li>➤ Wet gangrene</li><li>➤ superadded infection and putrefaction are present</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28 th Edition Page 35, 1008</li><li>➤ Ref :</li><li>➤ Bailey and Love’s Short Practice of Surgery 28 th Edition Page 35, 1008</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of these are components of diabetic foot except?", "options": [{"label": "A", "text": "Venous thrombosis", "correct": true}, {"label": "B", "text": "Micro-angiopathy", "correct": false}, {"label": "C", "text": "Neuropathy", "correct": false}, {"label": "D", "text": "Local sepsis", "correct": false}], "correct_answer": "A. Venous thrombosis", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Venous thrombosis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. Micro-angiopathy Micro-angiopathy, which refers to disease in the small blood vessels , is a significant component of diabetic foot . It leads to impaired circulation and contributes to ulcer formation and poor wound healing.</li><li>• Option B. Micro-angiopathy</li><li>• disease in the small blood vessels</li><li>• component of diabetic foot</li><li>• impaired circulation</li><li>• contributes to ulcer formation</li><li>• Option C. Neuropathy Peripheral neuropathy is a hallmark of diabetic foot, causing loss of sensation , which increases the risk of injury and delays the recognition of such injuries, leading to worse outcomes.</li><li>• Option C. Neuropathy</li><li>• Peripheral neuropathy</li><li>• diabetic foot, causing loss of sensation</li><li>• increases the risk of injury</li><li>• Option D. Local Sepsis Local sepsis can occur in the diabetic foot as a result of infection entering through ulcers or injuries , often exacerbated by the compromised immune response and vascular insufficiency associated with diabetes.</li><li>• Option D. Local Sepsis</li><li>• diabetic foot as a result of infection entering through ulcers or injuries</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Venous thrombosis is not typically associated with diabetic foot , which is mainly affected by micro-angiopathy, neuropathy, and increased risk of infection due to immunosuppression and high tissue glucose levels .</li><li>➤ Venous thrombosis</li><li>➤ not typically associated with diabetic foot</li><li>➤ affected by micro-angiopathy, neuropathy, and increased risk of infection due to immunosuppression</li><li>➤ high tissue glucose levels</li><li>➤ Diabetic gangrene is usually caused by a combination of three factors:</li><li>➤ Diabetic gangrene is usually caused by a combination of three factors:</li><li>➤ Ischemia secondary to macrovascular disease and microvascular dysfunction Peripheral sensorimotor neuropathy (PSN) , which leads to trophic skin changes Immunosuppression caused by an excess of sugar in the tissues, which predisposes to infection.</li><li>➤ Ischemia secondary to macrovascular disease and microvascular dysfunction</li><li>➤ Ischemia</li><li>➤ Peripheral sensorimotor neuropathy (PSN) , which leads to trophic skin changes</li><li>➤ Peripheral sensorimotor neuropathy (PSN)</li><li>➤ Immunosuppression caused by an excess of sugar in the tissues, which predisposes to infection.</li><li>➤ Immunosuppression</li><li>➤ Macro-vascular disease is atherosclerotic and typically affects the crural vessels with relative sparing of the pedal vessels, whereas increased microcirculatory shunting causes microvascular dysfunction. The PSN is usually sensory in the early phase – classically in a stocking distribution and renders the patients at high risk of soft-tissue injury and its subsequent neglect. The PSN may extend to the joints of the foot and ankle, resulting in loss of nociceptive and proprioceptive protective reflexes and a repeated cycle of joint injury and bony destruction. Motor involvement causes an imbalance between flexors and extensor muscle groups of the foot, promoting altered foot biomechanics and abnormal pressure loading, which result in thick callosities developing on the sole of the foot. Ischemia and PSN act synergistically to increase the risk of diabetic foot ulceration and reduce its subsequent healing potential. Superadded infection due to poor wound care can spread rapidly and proximally in subfascial planes, leading to fulminant foot sepsis, gangrene and death. Treatment depends on the degree of arterial involvement, which should be investigated and treated rapidly with angioplasty or surgery. The gangrene is treated by drainage of pus, liberal debridement of dead tissue and antibiotics. Unfortunately, a number of patients present with life-threatening systemic upset and should be considered for primary amputation.</li><li>➤ Macro-vascular disease is atherosclerotic and typically affects the crural vessels with relative sparing of the pedal vessels, whereas increased microcirculatory shunting causes microvascular dysfunction.</li><li>➤ The PSN is usually sensory in the early phase – classically in a stocking distribution and renders the patients at high risk of soft-tissue injury and its subsequent neglect. The PSN may extend to the joints of the foot and ankle, resulting in loss of nociceptive and proprioceptive protective reflexes and a repeated cycle of joint injury and bony destruction.</li><li>➤ Motor involvement causes an imbalance between flexors and extensor muscle groups of the foot, promoting altered foot biomechanics and abnormal pressure loading, which result in thick callosities developing on the sole of the foot.</li><li>➤ Ischemia and PSN act synergistically to increase the risk of diabetic foot ulceration and reduce its subsequent healing potential.</li><li>➤ Ischemia and PSN act synergistically to increase the risk of diabetic foot ulceration and reduce its subsequent healing potential.</li><li>➤ Superadded infection due to poor wound care can spread rapidly and proximally in subfascial planes, leading to fulminant foot sepsis, gangrene and death.</li><li>➤ Treatment depends on the degree of arterial involvement, which should be investigated and treated rapidly with angioplasty or surgery. The gangrene is treated by drainage of pus, liberal debridement of dead tissue and antibiotics. Unfortunately, a number of patients present with life-threatening systemic upset and should be considered for primary amputation.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1009-1010.</li><li>➤ Ref :</li><li>➤ Bailey and Love, 28 th Ed. Pg 1009-1010.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of these are true regarding decubitus ulcer except?", "options": [{"label": "A", "text": "Anemia and malnutrition contribute to its development", "correct": false}, {"label": "B", "text": "Most common site is the heel", "correct": true}, {"label": "C", "text": "A bedsore can be expected if erythema appears that does not change colour on pressure", "correct": false}, {"label": "D", "text": "Skin grafting should be avoided", "correct": false}], "correct_answer": "B. Most common site is the heel", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Most common site is the heel</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Anemia and malnutrition contribute to its development This statement is true . Anemia and malnutrition are systemic factors that can impair wound healing and contribute to the development of decubitus ulcers.</li><li>• Option A. Anemia and malnutrition contribute to its development</li><li>• true</li><li>• Option C. A bedsore can be expected if erythema appears that does not change colour on pressure This is true . Persistent erythema that does not blanch with pressure indicates the start of a pressure ulcer (stage 1).</li><li>• Option C. A bedsore can be expected if erythema appears that does not change colour on pressure</li><li>• true</li><li>• Option D. Skin grafting should be avoided This statement is generally true . Skin grafting is not the first-line treatment for bedsores, given the high risk of failure due to the compromised tissue health at the ulcer site. Other interventions like flaps are typically preferred.</li><li>• Option D. Skin grafting should be avoided</li><li>• true</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most common site for decubitus ulcers is over the ischial tuberosity , not the heel , and management often requires regular repositioning , use of pressure-distributing devices, and optimizing the local environment for wound healing.</li><li>➤ most common site for decubitus ulcers</li><li>➤ over the ischial tuberosity</li><li>➤ not the heel</li><li>➤ management often requires regular repositioning</li><li>➤ Pressure injuries should be regarded as preventable. There is a higher incidence in those who are severely ill, those who have impaired mobility or those with a significant loss of sensation. Common sites: Ischium, greater trochanter, heel. Bedsores are predisposed to by five factors: pressure, injury, anemia, malnutrition and moisture. Pressure required should be at least 30 mm of Hg. A bedsore can be expected if erythema appears that does not change colour on pressure Patients at risk of developing pressure injuries should have a skin assessment, regular repositioning every 2-4 hours and the use of pressure distributing devices as appropriate. Dressings should be chosen to create an optimum wound-healing environment and appropriate antibiotics given if there are signs of infection. Surgery is not first-line treatment and is only considered when others have failed. Primary closure and skin grafting should be avoided as they are likely to fail. In suitable patients, successful reconstruction options include the use of large fasciocutaneous or musculocutaneous flap.</li><li>➤ Pressure injuries should be regarded as preventable. There is a higher incidence in those who are severely ill, those who have impaired mobility or those with a significant loss of sensation.</li><li>➤ Common sites: Ischium, greater trochanter, heel.</li><li>➤ Common sites:</li><li>➤ Bedsores are predisposed to by five factors: pressure, injury, anemia, malnutrition and moisture.</li><li>➤ Bedsores are predisposed to by five factors:</li><li>➤ Pressure required should be at least 30 mm of Hg.</li><li>➤ Pressure required should be at least 30 mm of Hg.</li><li>➤ A bedsore can be expected if erythema appears that does not change colour on pressure</li><li>➤ Patients at risk of developing pressure injuries should have a skin assessment, regular repositioning every 2-4 hours and the use of pressure distributing devices as appropriate.</li><li>➤ Dressings should be chosen to create an optimum wound-healing environment and appropriate antibiotics given if there are signs of infection. Surgery is not first-line treatment and is only considered when others have failed.</li><li>➤ Primary closure and skin grafting should be avoided as they are likely to fail. In suitable patients, successful reconstruction options include the use of large fasciocutaneous or musculocutaneous flap.</li><li>➤ large fasciocutaneous or musculocutaneous flap.</li><li>➤ Ref : Bailey and Love, 27 th Ed. Pg 953, 28 th Ed. Pg 35.</li><li>➤ Ref :</li><li>➤ Bailey and Love, 27 th Ed. Pg 953, 28 th Ed. Pg 35.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the mismatch type of surgical wound?", "options": [{"label": "A", "text": "Clean wound- Mastectomy", "correct": false}, {"label": "B", "text": "Clean-contaminated- Breast abscess", "correct": true}, {"label": "C", "text": "Contaminated- Open cardiac massage", "correct": false}, {"label": "D", "text": "Dirty- Fournier’s gangrene", "correct": false}], "correct_answer": "B. Clean-contaminated- Breast abscess", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Clean-contaminated- Breast abscess</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ Breast abscess contains pus. Pus in wound is a dirty wound and not clean- contaminated.</li><li>➤ Ref : Bailey 28 th Ed. Pg 28.</li><li>➤ Ref : Bailey 28 th Ed. Pg 28.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In prolonged surgery, prophylactic antibiotics should be repeated at what intervals?", "options": [{"label": "A", "text": "2 hourly", "correct": false}, {"label": "B", "text": "4 hourly", "correct": true}, {"label": "C", "text": "6 hourly", "correct": false}, {"label": "D", "text": "No need to repeat after pre-operative dose", "correct": false}], "correct_answer": "B. 4 hourly", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) 4 hourly</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In prolonged surgeries , especially those lasting longer than 4 hours , or in the presence of excessive blood loss or additional contamination , prophylactic antibiotics should be repeated at 4-hourly intervals to maintain therapeutic tissue levels and prevent surgical site infections.</li><li>➤ prolonged surgeries</li><li>➤ lasting longer than 4 hours</li><li>➤ presence of excessive blood loss or additional contamination</li><li>➤ prophylactic antibiotics should be repeated at 4-hourly intervals</li><li>➤ therapeutic tissue levels</li><li>➤ Prevention of Surgical site infection (SSI):</li><li>➤ Medical and nursing staff should always wash their hands after any patient contact. Hand gels containing at least 70% alcohol can act as a substitute for handwashing. Preoperative skin shaving should be undertaken in the operating theatre immediately before surgery as the SSI rate after clean wound surgery may be doubled if shaving is performed the night before because minor skin injury enhances superficial bacterial colonization. Scrubbing and skin preparation: When washing the hands prior to surgery, dilute alcohol-based antiseptic hand soaps such as chlorhexidine or povidone– iodine should be used, and the scrub should include the nails. One application of a more concentrated alcohol-based antiseptic is adequate for skin preparation of the operative site .</li><li>➤ Medical and nursing staff should always wash their hands after any patient contact. Hand gels containing at least 70% alcohol can act as a substitute for handwashing.</li><li>➤ Hand gels containing at least 70% alcohol</li><li>➤ Preoperative skin shaving should be undertaken in the operating theatre immediately before surgery as the SSI rate after clean wound surgery may be doubled if shaving is performed the night before because minor skin injury enhances superficial bacterial colonization.</li><li>➤ Scrubbing and skin preparation: When washing the hands prior to surgery, dilute alcohol-based antiseptic hand soaps such as chlorhexidine or povidone– iodine should be used, and the scrub should include the nails.</li><li>➤ Scrubbing and skin preparation:</li><li>➤ One application of a more concentrated alcohol-based antiseptic is adequate for skin preparation of the operative site .</li><li>➤ One application</li><li>➤ concentrated alcohol-based antiseptic</li><li>➤ skin preparation of the operative site</li><li>➤ Antibiotics:</li><li>➤ Antibiotics:</li><li>➤ The value of antibiotic prophylaxis is low in non-prosthetic clean surgery, with most trials showing no clear benefit because infection rates without antibiotics are so low. The exception to this is where a prosthetic implant is used, as the results of infection are so catastrophic that even a small risk of infection is unacceptable. There is undisputed evidence that prophylactic antibiotics are effective in reducing the risk of infection in clean-contaminated and contaminated operations . When wounds are heavily contaminated or when an incision is made into an abscess, a 5-day course of therapeutic antibiotics may be justified. Tissue levels of the antibiotic should remain high throughout the operation and antibiotics with a short tissue half-life should be avoided. Intravenous administration at induction of anesthesia is therefore optimal , as unexpected delays in the timing of surgery may occur before then and antibiotic tissue levels may fall of before the surgery starts. In long operations or when there is excessive blood loss, or when unexpected contamination occurs, antibiotics may be repeated at 4-hourly intervals during the surgery because tissue antibiotic levels often fall faster than serum level.</li><li>➤ The value of antibiotic prophylaxis is low in non-prosthetic clean surgery, with most trials showing no clear benefit because infection rates without antibiotics are so low.</li><li>➤ The exception to this is where a prosthetic implant is used, as the results of infection are so catastrophic that even a small risk of infection is unacceptable.</li><li>➤ There is undisputed evidence that prophylactic antibiotics are effective in reducing the risk of infection in clean-contaminated and contaminated operations . When wounds are heavily contaminated or when an incision is made into an abscess, a 5-day course of therapeutic antibiotics may be justified.</li><li>➤ prophylactic antibiotics are effective in reducing the risk of infection in clean-contaminated and contaminated operations</li><li>➤ Tissue levels of the antibiotic should remain high throughout the operation and antibiotics with a short tissue half-life should be avoided.</li><li>➤ Intravenous administration at induction of anesthesia is therefore optimal , as unexpected delays in the timing of surgery may occur before then and antibiotic tissue levels may fall of before the surgery starts.</li><li>➤ Intravenous administration at induction of anesthesia is therefore optimal</li><li>➤ In long operations or when there is excessive blood loss, or when unexpected contamination occurs, antibiotics may be repeated at 4-hourly intervals during the surgery because tissue antibiotic levels often fall faster than serum level.</li><li>➤ antibiotics may be repeated at 4-hourly intervals</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 61.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 61.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Risk of SSI in clean-contaminated surgeries in the absence of prophylactic antibiotics is?", "options": [{"label": "A", "text": "1 to 2%", "correct": false}, {"label": "B", "text": "5 to 10%", "correct": true}, {"label": "C", "text": "10 to 20%", "correct": false}, {"label": "D", "text": "20 to 40%", "correct": false}], "correct_answer": "B. 5 to 10%", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/18/screenshot-2024-03-18-191415.jpg"], "explanation": "<p><strong>Ans. B) 5 to 10%</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 25-year-old female diagnosed with morbid obesity is planned for laparoscopic sleeve gastrectomy. Which of the following is not an advantage of advising patient for a minimal access surgery?", "options": [{"label": "A", "text": "Long learning curve", "correct": true}, {"label": "B", "text": "Reduced paralytic ileus", "correct": false}, {"label": "C", "text": "Improved visual field", "correct": false}, {"label": "D", "text": "Less wound pain", "correct": false}], "correct_answer": "A. Long learning curve", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Long learning curve</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Reduced paralytic ileus: Reduced incidence of paralytic ileus is an advantage of minimal access surgery because of the decreased manipulation of the intestines compared to open surgery.</li><li>• Option B: Reduced paralytic ileus:</li><li>• advantage of minimal access surgery</li><li>• decreased manipulation of the intestines</li><li>• Option C: Improved visual field: An improved visual field is also an advantage of minimal access surgery . The use of a laparoscope provides magnification and better lighting , enhancing visualization of the surgical field.</li><li>• Option C: Improved visual field:</li><li>• advantage of minimal access surgery</li><li>• use of a laparoscope</li><li>• magnification and better lighting</li><li>• Option D: Less wound pain: Less wound pain is an advantage of minimal access surgery due to smaller incisions and reduced tissue trauma .</li><li>• Option D: Less wound pain:</li><li>• advantage of minimal access surgery</li><li>• smaller incisions and reduced tissue trauma</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The long learning curve is not an advantage of minimal access surgery ; it is a limitation that needs to be addressed through proper training and experience . The benefits of such procedures include reduced paralytic ileus, improved visual field, and less wound pain.</li><li>➤ long learning curve</li><li>➤ not an advantage of minimal access surgery</li><li>➤ limitation that needs to be addressed through proper training and experience</li><li>➤ Advantages of minimal access surgery:</li><li>➤ Advantages of minimal access surgery:</li><li>➤ Decrease in wound size Reduction in wound infection, dehiscence, bleeding, herniation and nerve entrapment Decrease in wound pain Improved mobility Decreased wound trauma Decreased heat loss Improved visualization</li><li>➤ Decrease in wound size</li><li>➤ Reduction in wound infection, dehiscence, bleeding, herniation and nerve entrapment</li><li>➤ Decrease in wound pain</li><li>➤ Improved mobility</li><li>➤ Decreased wound trauma</li><li>➤ Decreased heat loss</li><li>➤ Improved visualization</li><li>➤ Limitations of minimal access surgery:</li><li>➤ Limitations of minimal access surgery:</li><li>➤ Lack of 3D vision Loss of tactile feedback Hemostasis Extraction of large specimens Learning curve and increased operative time Cost Reliance on new technologies</li><li>➤ Lack of 3D vision</li><li>➤ Loss of tactile feedback</li><li>➤ Hemostasis</li><li>➤ Extraction of large specimens</li><li>➤ Learning curve and increased operative time</li><li>➤ Cost</li><li>➤ Reliance on new technologies</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 164-165.</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 164-165.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "You are a 1st year PG in surgery department assisting the 3rd year PG in exploratory laparotomy for a patient with severe abdominal trauma. After the surgery and while closing the abdomen after a midline laparotomy, you were asked by your chief to suture the rectus sheath incision. What is the length of suture will you choose to close the incision?", "options": [{"label": "A", "text": "Twice the length of incision", "correct": false}, {"label": "B", "text": "Thrice the length of incision", "correct": false}, {"label": "C", "text": "4 times the length of incision", "correct": true}, {"label": "D", "text": "Same size the length of incision", "correct": false}], "correct_answer": "C. 4 times the length of incision", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/23/screenshot-2024-03-23-104348.png"], "explanation": "<p><strong>Ans. C) 4 times the length of incision</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• The length of suture depends upon the type of incision according to Jenkins rule</li><li>• length of suture depends upon the type of incision according to Jenkins rule</li><li>• Laparotomy incision - ratio of suture length to wound length is 4:1 Skin suturing - ratio of distance between sutures and skin thickness is 2:1 Layered versus mass closure of the abdomen . Abdominal wounds can be closed either by closing all layers of the abdomen (musculoaponeurotic layers avoiding skin) together or by closing individual layers of the rectus sheath. Continuous versus interrupted sutures - Simple continuous sutures theoretically seem to be better than interrupted sutures as the tension is evenly distributed, resulting in less ischemia; in addition, they are quicker to perform. Delayed absorbable monofilament material such as PDS is usually the suture material of choice. In patients with multiple previous operations, non-absorbable material such as nylon or polypropylene may be an alternative. Big bites, big needle versus small bites, small needle. Abdominal closure is commonly performed by placing the sutures 1 cm apart from each other and 1 cm from the fascial edge. Recent studies have shown decreased incisional hernia when the interval between sutures is reduced to 0.5 cm and performed using a smaller sized needle (2.0 PDS as opposed to the much larger 1 PDS)</li><li>• Laparotomy incision - ratio of suture length to wound length is 4:1</li><li>• Laparotomy incision</li><li>• 4:1</li><li>• Skin suturing - ratio of distance between sutures and skin thickness is 2:1</li><li>• Skin suturing</li><li>• 2:1</li><li>• Layered versus mass closure of the abdomen . Abdominal wounds can be closed either by closing all layers of the abdomen (musculoaponeurotic layers avoiding skin) together or by closing individual layers of the rectus sheath.</li><li>• Layered versus mass closure of the abdomen</li><li>• Continuous versus interrupted sutures - Simple continuous sutures theoretically seem to be better than interrupted sutures as the tension is evenly distributed, resulting in less ischemia; in addition, they are quicker to perform.</li><li>• Continuous versus interrupted sutures -</li><li>• Delayed absorbable monofilament material such as PDS is usually the suture material of choice. In patients with multiple previous operations, non-absorbable material such as nylon or polypropylene may be an alternative.</li><li>• Delayed absorbable monofilament material</li><li>• Big bites, big needle versus small bites, small needle. Abdominal closure is commonly performed by placing the sutures 1 cm apart from each other and 1 cm from the fascial edge. Recent studies have shown decreased incisional hernia when the interval between sutures is reduced to 0.5 cm and performed using a smaller sized needle (2.0 PDS as opposed to the much larger 1 PDS)</li><li>• Big bites, big needle versus small bites, small needle.</li><li>• decreased incisional hernia when the interval between sutures is reduced to 0.5 cm and performed using a smaller sized needle</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ When closing a midline laparotomy incision , it is advised to use a suture length that is four times the length of the incision to ensure proper wound closure and minimize the risk of complications like incisional hernia .</li><li>➤ closing a midline laparotomy incision</li><li>➤ use a suture length that is four times the length of the incision</li><li>➤ proper wound closure and minimize the risk of complications like incisional hernia</li><li>➤ Ref : Bailey and Love, 27 th Ed. Pg 86</li><li>➤ Ref</li><li>➤ : Bailey and Love, 27 th Ed. Pg 86</li><li>➤ Bailey and Love, 28 th Ed. Pg 108-109</li><li>➤ Bailey and Love, 28 th Ed. Pg 108-109</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 56-year-old woman comes to the hospital for a hysterectomy. The surgeon tells her about the advantages of using newer devices for surgery. What is incorrect about the device shown in the image?", "options": [{"label": "A", "text": "Provides 3D vision", "correct": false}, {"label": "B", "text": "Reduces tremors", "correct": false}, {"label": "C", "text": "Similar in cost to laparoscopic surgery", "correct": true}, {"label": "D", "text": "Provides 7 degrees of freedom with robotic wrist", "correct": false}], "correct_answer": "C. Similar in cost to laparoscopic surgery", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/untitled-204.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/untitled-205.jpg"], "explanation": "<p><strong>Ans. C) Similar in cost to laparoscopic surgery</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Provides 3D vision This statement is correct . The da Vinci surgical system provides the surgeon with a 3D high-definition view of the surgical field.</li><li>• Option A: Provides 3D vision</li><li>• correct</li><li>• Option B: Reduces tremors This is also true . The system filters out tremors in the surgeon's hands, allowing for more precise movements of the surgical instruments.</li><li>• Option B: Reduces tremors</li><li>• true</li><li>• Option D: Provides 7 degrees of freedom with robotic wrist This is true . The EndoWrist instruments used in the da Vinci system have a range of motion greater than the human hand, providing seven degrees of freedom which enhances surgical dexterity and precision.</li><li>• Option D: Provides 7 degrees of freedom with robotic wrist</li><li>• true</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The da Vinci surgical system offers advantages such as 3D vision , tremor reduction , and enhanced dexterity due to the robotic wrist , but it is not similar in cost to traditional laparoscopic surgery; it is generally more b.</li><li>➤ da Vinci surgical system offers advantages such as 3D vision</li><li>➤ tremor reduction</li><li>➤ enhanced dexterity due to the robotic wrist</li><li>➤ cost to traditional laparoscopic surgery;</li><li>➤ DaVinci robot is the most commonly used robotic device worldwide. Based on Master-Slave principle . During the procedure, the surgeon controls the robot sitting in the console (image in question) and this translates into movements of robotic arms (image shown below) which are connected the instruments at the operating field. Indications are - Prostatectomy, cardiac valve repair, gynecological operations The current era of surgical robots is dominated by the da Vinci® surgical system, which was first approved for clinical use in 2000. The system offers a number of advantages, including 3D surgical vision, EndoWrist® precision instruments, tremor reduction, and motion scaling and improved ergonomics. Improved maneuvering as a result of the ‘robotic wrist’ in some systems allows for up to seven degrees of freedom, thus improving dexterity for the surgeon The enclosed console system of many robotic systems also provides the advantage of surgical isolation from external distractions that may impact on the operator’s concentration. The disadvantage is reduced awareness of non-verbal communication , thus highlighting the importance of team training and regular verbal cues. Robotic surgery remains more costly than minimally invasive alternatives</li><li>➤ DaVinci robot is the most commonly used robotic device worldwide.</li><li>➤ DaVinci robot</li><li>➤ Based on Master-Slave principle .</li><li>➤ Master-Slave principle</li><li>➤ During the procedure, the surgeon controls the robot sitting in the console (image in question) and this translates into movements of robotic arms (image shown below) which are connected the instruments at the operating field.</li><li>➤ surgeon controls the robot sitting in the console</li><li>➤ Indications are - Prostatectomy, cardiac valve repair, gynecological operations</li><li>➤ Indications are</li><li>➤ The current era of surgical robots is dominated by the da Vinci® surgical system, which was first approved for clinical use in 2000.</li><li>➤ The system offers a number of advantages, including 3D surgical vision, EndoWrist® precision instruments, tremor reduction, and motion scaling and improved ergonomics.</li><li>➤ EndoWrist®</li><li>➤ Improved maneuvering as a result of the ‘robotic wrist’ in some systems allows for up to seven degrees of freedom, thus improving dexterity for the surgeon</li><li>➤ The enclosed console system of many robotic systems also provides the advantage of surgical isolation from external distractions that may impact on the operator’s concentration.</li><li>➤ advantage of surgical isolation from external distractions that may impact on the operator’s concentration.</li><li>➤ The disadvantage is reduced awareness of non-verbal communication , thus highlighting the importance of team training and regular verbal cues.</li><li>➤ disadvantage is reduced awareness of non-verbal communication</li><li>➤ Robotic surgery remains more costly than minimally invasive alternatives</li><li>➤ Robotic arms and instrument</li><li>➤ Robotic arms and instrument</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 166-167</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 166-167</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "35 years old healthy male is presented with a gunshot wound to right upper thigh region. On examination, the patient was hemodynamically stable but had no palpable lower extremity pulses on the injured side. On exploration, superficial femoral artery was transected. Which of the following is the suture material to be used for vascular repair?", "options": [{"label": "A", "text": "Polyglactin", "correct": false}, {"label": "B", "text": "PDS", "correct": false}, {"label": "C", "text": "Polypropylene", "correct": true}, {"label": "D", "text": "Linen", "correct": false}], "correct_answer": "C. Polypropylene", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Polypropylene</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Polyglactin (Vicryl) is a synthetic absorbable sterile suture. Copolymer of 90% glycol and 10% l-lactide . It retrains tensile strength of about 70% till 14 days after implantation, it is completely absorbed within 56-70 days by simple hydrolysis . Polydioxanone (PDS) is a synthetic absorbable sterile suture composed of polyester - p –dioxanone. It is suitable for cases where extended would support and strength are required. It retains about 70% of initial strength for 2 weeks, 50% for 4 weeks and 25% for 6 weeks and is absorbed through simple hydrolysis and completely absorbed within 180- 210 days . Delayed absorbable sutures like Vicryl and PDS are preferred for biliary and urological anastomosis where there is risk of foreign body inflammation and stone formation. Vicryl is also known as work-horse suture of general surgery. Linen is used for vascular ligation or for fixation of surgical drains.</li><li>• Polyglactin (Vicryl) is a synthetic absorbable sterile suture. Copolymer of 90% glycol and 10% l-lactide . It retrains tensile strength of about 70% till 14 days after implantation, it is completely absorbed within 56-70 days by simple hydrolysis .</li><li>• Copolymer of 90% glycol and 10% l-lactide</li><li>• completely absorbed within 56-70 days by simple hydrolysis</li><li>• Polydioxanone (PDS) is a synthetic absorbable sterile suture composed of polyester - p –dioxanone. It is suitable for cases where extended would support and strength are required. It retains about 70% of initial strength for 2 weeks, 50% for 4 weeks and 25% for 6 weeks and is absorbed through simple hydrolysis and completely absorbed within 180- 210 days .</li><li>• Polydioxanone (PDS) is a synthetic absorbable sterile suture</li><li>• completely absorbed within 180- 210 days</li><li>• Delayed absorbable sutures like Vicryl and PDS are preferred for biliary and urological anastomosis where there is risk of foreign body inflammation and stone formation.</li><li>• Delayed absorbable sutures like Vicryl and PDS are preferred for biliary and urological anastomosis</li><li>• Vicryl is also known as work-horse suture of general surgery.</li><li>• Vicryl is also known as work-horse suture of general surgery.</li><li>• Linen is used for vascular ligation or for fixation of surgical drains.</li><li>• Linen is used for vascular ligation or for fixation of surgical drains.</li><li>• Ref : Bailey and Love, 28 th Ed. page 105-106</li><li>• Ref</li><li>• : Bailey and Love, 28 th Ed. page 105-106</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "During interrupted skin suturing, at what angle is needle pierced into the skin?", "options": [{"label": "A", "text": "45 degrees", "correct": false}, {"label": "B", "text": "60 degrees", "correct": false}, {"label": "C", "text": "90 degrees", "correct": true}, {"label": "D", "text": "120 degrees", "correct": false}], "correct_answer": "C. 90 degrees", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/general-surgery-1_MsMpyAr.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/general-surgery-2.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/general-surgery-3.jpg"], "explanation": "<p><strong>Ans. C) 90 degrees</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these surgical blades is used to performing lipoma excision on forearm of size 2 cm?", "options": [{"label": "A", "text": "11 no.", "correct": false}, {"label": "B", "text": "15 no.", "correct": true}, {"label": "C", "text": "12 no.", "correct": false}, {"label": "D", "text": "21 no.", "correct": false}], "correct_answer": "B. 15 no.", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/untitled-206.jpg"], "explanation": "<p><strong>Ans. B) 15 no.</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ For the excision of a small lipoma on the forearm , a number 15 surgical blade is commonly used due to its precise cutting edge suitable for minor surgical procedures .</li><li>➤ excision of a small lipoma on the forearm</li><li>➤ number 15 surgical blade</li><li>➤ used due to its precise cutting edge</li><li>➤ minor surgical procedures</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 98</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 98</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the incorrect statement about the device in the image?", "options": [{"label": "A", "text": "Allows CO 2 flow of 20L/min", "correct": true}, {"label": "B", "text": "Commonly placed at left subcostal area", "correct": false}, {"label": "C", "text": "Used in closed technique of pneumoperitoneum", "correct": false}, {"label": "D", "text": "Blunt advancing tip reduces trauma", "correct": false}], "correct_answer": "A. Allows CO 2 flow of 20L/min", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/untitled-207.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/untitled-208.jpg"], "explanation": "<p><strong>Ans. A) Allows CO2flow of 20/L min</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Commonly placed at left subcostal area This statement is true . The Veress needle can be inserted at Palmer’s point, which is 3 cm below the left costal margin in the mid-clavicular line.</li><li>• Option B: Commonly placed at left subcostal area</li><li>• true</li><li>• Option C: Used in closed technique of pneumoperitoneum This is correct . The Veress needle is indeed used in the closed technique for establishing pneumoperitoneum in laparoscopic surgeries.</li><li>• Option C: Used in closed technique of pneumoperitoneum</li><li>• correct</li><li>• Option D: Blunt advancing tip reduces trauma This statement is true . The Veress needle has a spring-loaded blunt inner stylet that advances once the needle enters the peritoneal cavity, reducing the risk of trauma to internal organs.</li><li>• Option D: Blunt advancing tip reduces trauma</li><li>• true</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Veress needle , used for establishing pneumoperitoneum in laparoscopic surgery, has a slow CO2 insufflation rate , is commonly placed at the left subcostal area , and features a blunt advancing tip to reduce internal organ trauma . It does not typically allow for CO2 flow of 20L/min.</li><li>➤ Veress needle</li><li>➤ pneumoperitoneum in laparoscopic surgery,</li><li>➤ slow CO2 insufflation rate</li><li>➤ placed at the left subcostal area</li><li>➤ blunt advancing tip to reduce internal organ trauma</li><li>➤ does not typically allow for CO2 flow</li><li>➤ A Veress needle is a spring-loaded needle that consists of an outer sharp bevel that cuts through tissue. Once the needle enters the peritoneal cavity, owing to the loss of resistance the spring-loaded blunt inner stylet deploys and prevents inadvertent injury to the bowel or blood vessels. The Veress needle can be inserted in the umbilical region or in other regions of the abdomen, such as Palmer’s point . A 10-mm incision in Palmer’s point (3 cm below the left costal margin, in the mid-clavicular plane) is the location preferred by many surgeons for Veress needle insertion. The needle is advanced until it reaches the muscle. The abdominal wall is then lifted and the needle advanced through the oblique muscles. Classically, a ‘pop’ is heard and a ‘give’ felt on successful insertion into the peritoneal cavity . The intraperitoneal placement is confirmed using a combination of the following techniques:</li><li>➤ A Veress needle is a spring-loaded needle that consists of an outer sharp bevel that cuts through tissue. Once the needle enters the peritoneal cavity, owing to the loss of resistance the spring-loaded blunt inner stylet deploys and prevents inadvertent injury to the bowel or blood vessels. The Veress needle can be inserted in the umbilical region or in other regions of the abdomen, such as Palmer’s point .</li><li>➤ The Veress needle can be inserted in the umbilical region or in other regions of the abdomen, such as Palmer’s point</li><li>➤ A 10-mm incision in Palmer’s point (3 cm below the left costal margin, in the mid-clavicular plane) is the location preferred by many surgeons for Veress needle insertion.</li><li>➤ The needle is advanced until it reaches the muscle. The abdominal wall is then lifted and the needle advanced through the oblique muscles.</li><li>➤ Classically, a ‘pop’ is heard and a ‘give’ felt on successful insertion into the peritoneal cavity .</li><li>➤ Classically, a ‘pop’ is heard and a ‘give’ felt on successful insertion into the peritoneal cavity</li><li>➤ The intraperitoneal placement is confirmed using a combination of the following techniques:</li><li>➤ The intraperitoneal placement is confirmed using a combination of the following techniques:</li><li>➤ The hanging drop method , wherein a drop of water is placed in the hub of the needle; on elevating the abdominal wall the resultant loss of intra-abdominal pressure would result in the drop emptying into the abdominal cavity. Free flow of saline into the peritoneal cavity and no return of bowel content or blood on aspiration. Abdominal pressure reading of less than 10 mmHg .</li><li>➤ The hanging drop method , wherein a drop of water is placed in the hub of the needle; on elevating the abdominal wall the resultant loss of intra-abdominal pressure would result in the drop emptying into the abdominal cavity.</li><li>➤ The hanging drop method</li><li>➤ Free flow of saline into the peritoneal cavity and no return of bowel content or blood on aspiration.</li><li>➤ Free flow of saline into the peritoneal cavity</li><li>➤ Abdominal pressure reading of less than 10 mmHg .</li><li>➤ Abdominal pressure reading of less than 10 mmHg</li><li>➤ Once the position is confirmed CO 2 insufflation at a slow pace of 2 to 3 L/ minute is commenced until the target pressure is reached. The needle is now removed.</li><li>➤ Once the position is confirmed CO 2 insufflation at a slow pace of 2 to 3 L/ minute is commenced until the target pressure is reached. The needle is now removed.</li><li>➤ 2 to 3 L/ minute</li><li>➤ Open technique of pneumoperitoneum by laparoscopic access to the abdomen using the modified Hasson’s technique:</li><li>➤ Open technique of pneumoperitoneum by laparoscopic access to the abdomen using the modified Hasson’s technique:</li><li>➤ Umbilicus everted , revealing the stalk of the umbilicus. Periumbilical skin incision . The junction of the umbilicus and Linea alba is identified and opened longitudinally. A curved hemostat used to break the peritoneum, which is then stretched open. A blunt-tipped primary trocar is inserted.</li><li>➤ Umbilicus everted , revealing the stalk of the umbilicus.</li><li>➤ Umbilicus everted</li><li>➤ Periumbilical skin incision .</li><li>➤ Periumbilical skin incision</li><li>➤ The junction of the umbilicus and Linea alba is identified and opened longitudinally.</li><li>➤ A curved hemostat used to break the peritoneum, which is then stretched open.</li><li>➤ A blunt-tipped primary trocar is inserted.</li><li>➤ Hasson trocar</li><li>➤ Hasson trocar</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 99-102</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 99-102</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these knots is not secure?", "options": [{"label": "A", "text": "Reef knot", "correct": false}, {"label": "B", "text": "Granny knot", "correct": true}, {"label": "C", "text": "Square knot", "correct": false}, {"label": "D", "text": "Aberdeen knot", "correct": false}], "correct_answer": "B. Granny knot", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/23/screenshot-2024-03-23-110241.png"], "explanation": "<p><strong>Ans. B) Granny knot</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Reef knot. The reef knot, also known as the square knot , is secure when tied correctly and is commonly used in surgery.</li><li>• Option A: Reef knot.</li><li>• also known as the square knot</li><li>• secure when tied correctly</li><li>• Option C: Square knot. The square knot is another name for the reef knot and is secure when tied correctly , with additional throws added for monofilament sutures.</li><li>• Option C: Square knot.</li><li>• another name for the reef knot</li><li>• secure when tied correctly</li><li>• Option D: Aberdeen knot. The Aberdeen knot is secure and often used to finish continuous suturing techniques .</li><li>• Option D: Aberdeen knot.</li><li>• secure and often used to finish continuous suturing techniques</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The granny knot is not considered secure for surgical purposes because it is prone to slipping, unlike the reef knot (or square knot) and the Aberdeen knot , which are both secure and commonly used in surgical practice.</li><li>➤ granny knot</li><li>➤ not considered secure for surgical purposes</li><li>➤ prone to slipping, unlike the reef knot</li><li>➤ Aberdeen knot</li><li>➤ The standard surgical knot is the reef knot/square knot with a third throw for security , although with monofilament sutures six throws are required for security. When added security is required , a surgeon’s knot using a two-throw technique is advisable to prevent slippage. When using a continuous suture technique, an Aberdeen knot may be used for the final knot . When the suture is cut after knotting , the ends should be left about 1–2 mm long to prevent unravelling. This is particularly important when using monofilament material.</li><li>➤ The standard surgical knot is the reef knot/square knot with a third throw for security , although with monofilament sutures six throws are required for security.</li><li>➤ standard surgical knot is the reef knot/square knot</li><li>➤ third throw for security</li><li>➤ When added security is required , a surgeon’s knot using a two-throw technique is advisable to prevent slippage.</li><li>➤ When added security is required</li><li>➤ surgeon’s knot using a two-throw technique</li><li>➤ When using a continuous suture technique, an Aberdeen knot may be used for the final knot .</li><li>➤ When using a continuous suture technique, an Aberdeen knot may be used for the final knot</li><li>➤ When the suture is cut after knotting , the ends should be left about 1–2 mm long to prevent unravelling.</li><li>➤ suture is cut after knotting</li><li>➤ ends should be left about 1–2 mm long</li><li>➤ This is particularly important when using monofilament material.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 108-109, 27 th Ed. PG 96</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 108-109, 27 th Ed. PG 96</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 40-year-old man is admitted for a surgery using NOTES procedure. The device shown in image is a Master and Slave robotic system used to perform this procedure. In this procedure, the entry point is through which of the following sites?", "options": [{"label": "A", "text": "Abdomen", "correct": false}, {"label": "B", "text": "Umbilicus", "correct": false}, {"label": "C", "text": "Mouth", "correct": true}, {"label": "D", "text": "Axilla", "correct": false}], "correct_answer": "C. Mouth", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/05/suturing-laparoscopy-and-robotics-11.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Mouth</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "An intern is asked by her resident about the type of sutures and their preferred uses. Which of the following statements if correct?", "options": [{"label": "A", "text": "Catgut is naturally absorbable suture", "correct": true}, {"label": "B", "text": "Monocryl is used for sternotomy closure", "correct": false}, {"label": "C", "text": "Vicryl is preferred suture for vascular anastomosis", "correct": false}, {"label": "D", "text": "Prolene/polypropylene suture for bile duct and bladder", "correct": false}], "correct_answer": "A. Catgut is naturally absorbable suture", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Catgut is natural absorbable suture</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. Monocryl is used for sternotomy closure : Monocryl is an absorbable suture known for its good handling and relatively rapid absorption , but it is not typically used for sternotomy closure. Stainless steel wires are the preferred choice for sternotomy closure due to their strength and non-absorbable nature.</li><li>• Option B. Monocryl is used for sternotomy closure</li><li>• absorbable suture known for its good handling</li><li>• relatively rapid absorption</li><li>• Option C. Vicryl is preferred suture for vascular anastomosis : Vicryl is a synthetic poly-filament absorbable suture material commonly used in general surgery but is not the preferred suture for vascular anastomosis. Proline, a non-absorbable synthetic suture, is generally preferred for vascular anastomosis due to its non-reactivity and smooth surface.</li><li>• Option C. Vicryl is preferred suture for vascular anastomosis</li><li>• synthetic poly-filament absorbable suture material</li><li>• general surgery but is not the preferred suture for vascular anastomosis.</li><li>• Option D. Proline suture for bile duct and bladder : Proline is not typically used for the bile duct and bladder ; instead, Vicryl is often the preferred choice because it is absorbable and has the necessary strength for these tissues. Nonabsorbable sutures can serve as a nidus for future stone formation and are avoided.</li><li>• Option D. Proline suture for bile duct and bladder</li><li>• not typically used for the bile duct and bladder</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Catgut is a naturally absorbable suture material that is used when the body requires the suture to be absorbed over time , such as in internal tissue layers .</li><li>➤ Catgut is a naturally absorbable suture material</li><li>➤ used when the body requires the suture to be absorbed over time</li><li>➤ internal tissue layers</li><li>➤ Workhouse suture for general surgeries - Vicryl Preferred suture for vascular anastomosis - Proline Preferred suture for bile duct and bladder - Vicryl Lowest affinity to the adherence of e coli and staph. aureus - PDS MC used for subcuticular - Monocryl. Preferred suture for sternotomy - Stainless steel</li><li>➤ Workhouse suture for general surgeries - Vicryl</li><li>➤ Vicryl</li><li>➤ Preferred suture for vascular anastomosis - Proline</li><li>➤ Proline</li><li>➤ Preferred suture for bile duct and bladder - Vicryl</li><li>➤ Vicryl</li><li>➤ Lowest affinity to the adherence of e coli and staph. aureus - PDS</li><li>➤ PDS</li><li>➤ MC used for subcuticular - Monocryl.</li><li>➤ Monocryl.</li><li>➤ Preferred suture for sternotomy - Stainless steel</li><li>➤ Stainless steel</li><li>➤ Ref : Bailey and Love, 27 th Ed. PG 92,93</li><li>➤ Ref</li><li>➤ : Bailey and Love, 27 th Ed. PG 92,93</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 1-year-old child was diagnosed with ileo-colic intussusception and is undergoing resection and anastomosis. In this intestinal anastomosis, strength is mainly provided by which of the following layer of the bowel?", "options": [{"label": "A", "text": "Mucosa", "correct": false}, {"label": "B", "text": "Submucosa", "correct": true}, {"label": "C", "text": "Serosa", "correct": false}, {"label": "D", "text": "Muscularis mucosa", "correct": false}], "correct_answer": "B. Submucosa", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Submucosa</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Submucosa has high collagen content and is the most stable suture layer in all sections of the GIT . Mucosa, serosa and muscularis mucosa do not have enough collagen content . Therefore, do not have enough strength for anastomosis. “The extra mucosal suture must include the submucosa because this has high collagen content and is the most stable suture layer in all sections of the gastrointestinal tract .” There are several prospective randomised trials comparing two-layer and single-layer anastomoses demonstrating that there is probably little to choose between these techniques, provided basic essentials are observed. However, catgut and silk have been replaced by synthetic, usually absorbable, polymers .</li><li>• Submucosa has high collagen content and is the most stable suture layer in all sections of the GIT .</li><li>• Submucosa has high collagen content</li><li>• most stable suture layer in all sections of the GIT</li><li>• Mucosa, serosa and muscularis mucosa do not have enough collagen content . Therefore, do not have enough strength for anastomosis.</li><li>• Mucosa, serosa and muscularis mucosa</li><li>• do not have enough collagen content</li><li>• “The extra mucosal suture must include the submucosa because this has high collagen content and is the most stable suture layer in all sections of the gastrointestinal tract .”</li><li>• “The extra mucosal suture must include the submucosa because this has high collagen content and is the most stable suture layer in all sections of the gastrointestinal tract</li><li>• There are several prospective randomised trials comparing two-layer and single-layer anastomoses demonstrating that there is probably little to choose between these techniques, provided basic essentials are observed. However, catgut and silk have been replaced by synthetic, usually absorbable, polymers .</li><li>• However, catgut and silk have been replaced by synthetic, usually absorbable, polymers</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In intestinal anastomosis , the submucosa provides the main strength due to its high collagen content , which is critical for the stability and integrity of the sutured connection between bowel segments.</li><li>➤ intestinal anastomosis</li><li>➤ submucosa provides the main strength</li><li>➤ high collagen content</li><li>➤ critical for the stability</li><li>➤ integrity of the sutured connection between bowel segments.</li><li>➤ Ref : Bailey and Love, 27 th Ed. Pg. 98</li><li>➤ Ref</li><li>➤ : Bailey and Love, 27 th Ed. Pg. 98</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the correct statement from the following?", "options": [{"label": "A", "text": "Kocher’s 2-layer method is the preferred technique for small bowel anastomosis", "correct": false}, {"label": "B", "text": "10-0 Proline sutures for used for popliteal artery suturing", "correct": false}, {"label": "C", "text": "Tissue glue is made up of a solution of n-butyle-2-cyanoacrylate monomer", "correct": true}, {"label": "D", "text": "Lightweight mesh typically has a weight is &lt;60 gm/m2", "correct": false}], "correct_answer": "C. Tissue glue is made up of a solution of n-butyle-2-cyanoacrylate monomer", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Tissue glue is made up of a solution of n-butyle-2-cyanoacrylate monomer</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Kocher’s 2-layer anastomosis is preferred for bowel anastomosis - Kocher’s method did utilize a two-layer anastomosis , but it is not the preferred method for all bowel anastomosis procedures today . Techniques have evolved, and the preference for anastomosis technique single layered extra-mucosal technique of Halstead.</li><li>• Option A: Kocher’s 2-layer anastomosis is preferred for bowel anastomosis</li><li>• Kocher’s method</li><li>• utilize a two-layer anastomosis</li><li>• not the preferred method for all bowel anastomosis procedures today</li><li>• Option B: 10-0 Proline sutures for used for popliteal artery suturing - Proline sutures are indeed used for vascular anastomoses because of their non-absorbable nature and low reactivity , but 10-0 suture is typically used for microvascular anastomoses , not commonly for popliteal arteries, which usually require larger suture sizes like 6-0.</li><li>• Option B: 10-0 Proline sutures for used for popliteal artery suturing</li><li>• indeed used for vascular anastomoses</li><li>• non-absorbable nature and low reactivity</li><li>• but 10-0 suture</li><li>• microvascular anastomoses</li><li>• Option D: Lightweight mesh weight is &lt;60 gm/m2 - In hernia repair , meshes are used to provide additional support to the weakened area . A lightweight mesh typically weighs less than 40 gm/m2, not 60 gm/m2.</li><li>• Option D: Lightweight mesh weight is &lt;60 gm/m2</li><li>• hernia repair</li><li>• meshes</li><li>• provide additional support to the weakened area</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Tissue glue , an alternative method for wound closure, is composed of a solution of n-butyl-2-cyanoacrylate monomer , which polymerizes to form a strong bond for effective closure of clean, dry wounds with minimal tension.</li><li>➤ Tissue glue</li><li>➤ composed of a solution of n-butyl-2-cyanoacrylate monomer</li><li>➤ polymerizes to form a strong bond for effective closure of clean, dry wounds</li><li>➤ Tissue glue or adhesives can be used to approximate wounds that do not require deep layer closure and do not have significant tension on the edges of the wound. It provides an alternative method for wound closure that is painless, fast and does not require a follow up visit for removal. Is made up of a solution n-butyl-2-cyanoacrylate monomer. When applied to a wound, it polymerases to form a firm adhesive bond which causes the closure of the wound. The wound does need to be clean and dry, with near perfect hemostasis, and under no tension for effective closure. It is relatively expensive, quick to use and does not delay wound healing, and is associated with allegedly low infection rate. Halsted and Matheson - one layer extra mucosal closure - least tissue necrosis and luminal narrowing is now widely accepted for bowel anastomosis.</li><li>➤ Tissue glue or adhesives can be used to approximate wounds that do not require deep layer closure and do not have significant tension on the edges of the wound. It provides an alternative method for wound closure that is painless, fast and does not require a follow up visit for removal. Is made up of a solution n-butyl-2-cyanoacrylate monomer.</li><li>➤ When applied to a wound, it polymerases to form a firm adhesive bond which causes the closure of the wound. The wound does need to be clean and dry, with near perfect hemostasis, and under no tension for effective closure. It is relatively expensive, quick to use and does not delay wound healing, and is associated with allegedly low infection rate.</li><li>➤ Halsted and Matheson - one layer extra mucosal closure - least tissue necrosis and luminal narrowing is now widely accepted for bowel anastomosis.</li><li>➤ Halsted and Matheson - one layer extra mucosal closure - least tissue necrosis and luminal narrowing is now widely accepted for bowel anastomosis.</li><li>➤ Other techniques:</li><li>➤ Other techniques:</li><li>➤ Lambert described his seromuscular suture technique for bowel anastomosis in 1826. Senn advocated a two-layer technique for closure. Kocher’s method utilised a two-layer anastomosis , first a continuous all-layer suture using catgut, then an inverting continuous (or interrupted) seromuscular layer suture using silk, which became the mainstay of bowel anastomoses for many years. Vascular anastomosis requires more precision than bowel anastomosis as they must be immediately watertight at the end of operation when the clamps are removed. Suture size depends on the vessel caliber - 2-0 for aorta, 4-0 for femoral artery, 6-0 for popliteal to distal arteries. Microvascular anatomies are made using a loupe and an interrupted suture of 10-0 size. Lightweight mesh is &lt; 40gm/m 2 heavy weight mesh is &gt; 80gm/m 2 .</li><li>➤ Lambert described his seromuscular suture technique for bowel anastomosis in 1826.</li><li>➤ Senn advocated a two-layer technique for closure.</li><li>➤ Kocher’s method utilised a two-layer anastomosis , first a continuous all-layer suture using catgut, then an inverting continuous (or interrupted) seromuscular layer suture using silk, which became the mainstay of bowel anastomoses for many years.</li><li>➤ Kocher’s method utilised a two-layer anastomosis</li><li>➤ Vascular anastomosis requires more precision than bowel anastomosis as they must be immediately watertight at the end of operation when the clamps are removed. Suture size depends on the vessel caliber - 2-0 for aorta, 4-0 for femoral artery, 6-0 for popliteal to distal arteries. Microvascular anatomies are made using a loupe and an interrupted suture of 10-0 size.</li><li>➤ Suture size depends on the vessel caliber</li><li>➤ Lightweight mesh is &lt; 40gm/m 2 heavy weight mesh is &gt; 80gm/m 2 .</li><li>➤ Lightweight mesh is &lt; 40gm/m 2 heavy weight mesh is &gt; 80gm/m 2</li><li>➤ Ref : Bailey and Love, 27 th Ed. Pg 96, 97, 99</li><li>➤ Ref</li><li>➤ : Bailey and Love, 27 th Ed. Pg 96, 97, 99</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the device used in laparoscopic surgery in the image?", "options": [{"label": "A", "text": "Light source", "correct": false}, {"label": "B", "text": "Camera source", "correct": false}, {"label": "C", "text": "CO 2 machine", "correct": true}, {"label": "D", "text": "Energy device (cautery) machine", "correct": false}], "correct_answer": "C. CO 2 machine", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/untitled-210.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/untitled-211.jpg"], "explanation": "<p><strong>Ans. C) CO2machine</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Light Source - A light source is used in laparoscopic surgery to illuminate the operative field inside the body . The device in the image does not resemble a typical light source unit, which usually has connections for light cables.</li><li>• Option A: Light Source</li><li>• laparoscopic surgery to illuminate the operative field inside the body</li><li>• Option B: Camera Source - The camera source or processor is the component that receives the visual information from the laparoscope and processes it for display on the monitors . This device does not have the typical video input and output ports that are found on a camera source.</li><li>• Option B: Camera Source</li><li>• processor is the component that receives the visual information from the laparoscope and processes</li><li>• display on the monitors</li><li>• Option D: Energy Device (cautery) Machine - An energy device such as an electrocautery machine is used to cut tissue and control bleeding by applying high-frequency electrical currents . The image does not show a device that resembles an electrocautery machine, which would typically have controls for power settings and types of current.</li><li>• Option D: Energy Device (cautery) Machine</li><li>• electrocautery machine is used to cut tissue and control bleeding by applying high-frequency electrical currents</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The device in the image is a CO2 insufflator , which is used in laparoscopic surgery to control the flow of CO2 for creating pneumoperitoneum, necessary for providing the surgeon with space to operate within the abdomen.</li><li>➤ device in the image is a CO2 insufflator</li><li>➤ used in laparoscopic surgery to control the flow of CO2</li><li>➤ creating pneumoperitoneum,</li><li>➤ Modern theatres are designed with moveable booms for video , diathermy and laparoscopic equipment with at least two high-resolution, high-definition (HD) or ultra-high-definition (4K) monitors, a carbon dioxide supply and flow monitor and appropriate audiovisual kit.</li><li>➤ Modern theatres are designed with moveable booms for video , diathermy and laparoscopic equipment with at least two high-resolution, high-definition (HD) or ultra-high-definition (4K) monitors, a carbon dioxide supply and flow monitor and appropriate audiovisual kit.</li><li>➤ Modern theatres</li><li>➤ designed with moveable booms for video</li><li>➤ diathermy and laparoscopic equipment</li><li>➤ least two high-resolution, high-definition</li><li>➤ ultra-high-definition</li><li>➤ a carbon dioxide supply</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is incorrect about energy sources in surgery?", "options": [{"label": "A", "text": "Monopolar energy can both coagulate and cut tissue.", "correct": false}, {"label": "B", "text": "Bipolar energy is preferred in areas of nerves.", "correct": false}, {"label": "C", "text": "Monopolar energy is safe in patients with cardiac pacemakers.", "correct": true}, {"label": "D", "text": "A patient return electrode is required in monopolar cautery.", "correct": false}], "correct_answer": "C. Monopolar energy is safe in patients with cardiac pacemakers.", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/7.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/9.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/8.jpg"], "explanation": "<p><strong>Ans. C) Monopolar energy is safe in patients with cardiac pacemakers.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Monopolar energy can coagulate and cut both. - This is a correct statement. Monopolar energy devices use a single electrode to deliver energy to the surgical site, allowing the surgeon to coagulate (stop bleeding by clotting blood) and cut tissues.</li><li>• Option A: Monopolar energy can coagulate and cut both.</li><li>• correct statement.</li><li>• Option B: Bipolar energy is preferred in areas of nerves. - This is also correct . Bipolar energy allows for more precise energy delivery with less spread, which is why it is preferred when operating near nerves to avoid collateral damage.</li><li>• Option B: Bipolar energy is preferred in areas of nerves.</li><li>• correct</li><li>• Option D: A patients return electrode is required in monopolar cautery. - This is correct . In monopolar cautery, the electrical circuit is completed by a return electrode, often referred to as a \"grounding pad,\" which is placed on the patient's body to safely disperse the electrical current.</li><li>• Option D: A patients return electrode is required in monopolar cautery.</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The use of monopolar energy is not safe in patients with cardiac pacemakers due to the risk of interference with the device's function , making this the incorrect statement among the options provided.</li><li>➤ use of monopolar energy</li><li>➤ not safe in patients with cardiac pacemakers</li><li>➤ due to the risk of interference with the device's function</li><li>➤ In monopolar surgery , the electrical current created in the Electro-Surgical Unit (ESU) passes through a single electrode (diathermy pencil) to the tissue, causing the desired tissue effect (cut or coagulation). To complete the cycle, the current then passes through the tissues and returns via a very large surface plate (the indifferent electrode or dispersive cable) back to the earth pole of the generator. The passage of current through the body tissues can interfere with cardiac pacemaker. In bipolar diathermy, the two active electrodes are usually represented by the limbs of a pair of diathermy forceps, blades of scissors or graspers. Both forceps ends are therefore active and current flows between them and only the tissue held between the limbs of the forceps heats up. This form of diathermy is used when working in sensitive areas (e.g. near the recurrent laryngeal nerve in thyroid surgery) or in patients with implantable electrical devices, as current can interfere with these devices. A separate return electrode (the indifferent electrode) to return current is not needed. Burns are the most common type of diathermy accidents and occur when the current flows in some way other than that which the surgeon intended; they are far more common in monopolar than bipolar.</li><li>➤ In monopolar surgery , the electrical current created in the Electro-Surgical Unit (ESU) passes through a single electrode (diathermy pencil) to the tissue, causing the desired tissue effect (cut or coagulation). To complete the cycle, the current then passes through the tissues and returns via a very large surface plate (the indifferent electrode or dispersive cable) back to the earth pole of the generator. The passage of current through the body tissues can interfere with cardiac pacemaker.</li><li>➤ monopolar surgery</li><li>➤ electrical current created in the Electro-Surgical Unit</li><li>➤ passes through a single electrode</li><li>➤ causing the desired tissue effect</li><li>➤ very large surface plate</li><li>➤ In bipolar diathermy, the two active electrodes are usually represented by the limbs of a pair of diathermy forceps, blades of scissors or graspers. Both forceps ends are therefore active and current flows between them and only the tissue held between the limbs of the forceps heats up. This form of diathermy is used when working in sensitive areas (e.g. near the recurrent laryngeal nerve in thyroid surgery) or in patients with implantable electrical devices, as current can interfere with these devices. A separate return electrode (the indifferent electrode) to return current is not needed.</li><li>➤ This form of diathermy is used when working in sensitive areas (e.g. near the recurrent laryngeal nerve in thyroid surgery) or in patients with implantable electrical devices, as current can interfere with these devices.</li><li>➤ Burns are the most common type of diathermy accidents and occur when the current flows in some way other than that which the surgeon intended; they are far more common in monopolar than bipolar.</li><li>➤ Burns</li><li>➤ are the most common type of diathermy accidents</li><li>➤ Monopolar circuit</li><li>➤ Monopolar circuit</li><li>➤ Bipolar circuit</li><li>➤ Bipolar circuit</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 110-111.</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 110-111.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Advanced bipolar energy sources can coagulate vessels directly upto what diameter?", "options": [{"label": "A", "text": "Upto 5 mm", "correct": false}, {"label": "B", "text": "Upto 7 mm", "correct": true}, {"label": "C", "text": "Upto 9 mm", "correct": false}, {"label": "D", "text": "Upto 11 mm", "correct": false}], "correct_answer": "B. Upto 7 mm", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Upto 7 mm</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Surgeons have increasingly used advanced energy devices to facilitate dissection and to seal and divide blood vessels up to 7 mm in diameter .</li><li>• Surgeons have increasingly used advanced energy devices</li><li>• facilitate dissection</li><li>• seal and divide blood vessels up to 7 mm in diameter</li><li>• There are three main types of advanced energy devices: bipolar electrosurgery, ultrasonic electrosurgery and combination device. Bipolar: New technology such as the LigaSure™ system (Medtronic) involves advanced bipolar technology that uses the body’s collagen and elastin to both seal and divide, allowing surgeons to reduce instrument handling when dissecting, ligating and grasping - a valuable asset particularly during laparoscopic surgery. The feedback-sensing technology incorporated in the instrument is designed to manage the energy delivery in a precise manner and results in automatic discontinuation of energy once the seal is complete. Ultra-sonic: The harmonic scalpel is an instrument that uses ultrasound technology to cut tissues while simultaneously sealing them. It utilizes a hand-held ultrasound transducer and scalpel that is controlled by a hand switch or foot pedal. During use, the scalpel vibrates in the 20 000–50 000-Hz range and cuts through tissues, effecting haemostasis by sealing vessels and tissues by means of protein denaturation caused by vibration rather than heat (in a similar manner to whisking an egg white). One product, the Thunder beat STM (Olympus) , has combined both modalities in a single device. By simultaneously using ultrasonic vibration and bipolar diathermy, this device can seal and divide arteries and veins up to 7 mm in diameter .</li><li>• There are three main types of advanced energy devices: bipolar electrosurgery, ultrasonic electrosurgery and combination device.</li><li>• Bipolar: New technology such as the LigaSure™ system (Medtronic) involves advanced bipolar technology that uses the body’s collagen and elastin to both seal and divide, allowing surgeons to reduce instrument handling when dissecting, ligating and grasping - a valuable asset particularly during laparoscopic surgery. The feedback-sensing technology incorporated in the instrument is designed to manage the energy delivery in a precise manner and results in automatic discontinuation of energy once the seal is complete.</li><li>• Bipolar:</li><li>• LigaSure™</li><li>• The feedback-sensing technology</li><li>• incorporated in the instrument is designed to manage the energy delivery in a precise manner</li><li>• Ultra-sonic: The harmonic scalpel is an instrument that uses ultrasound technology to cut tissues while simultaneously sealing them. It utilizes a hand-held ultrasound transducer and scalpel that is controlled by a hand switch or foot pedal. During use, the scalpel vibrates in the 20 000–50 000-Hz range and cuts through tissues, effecting haemostasis by sealing vessels and tissues by means of protein denaturation caused by vibration rather than heat (in a similar manner to whisking an egg white).</li><li>• Ultra-sonic:</li><li>• One product, the Thunder beat STM (Olympus) , has combined both modalities in a single device. By simultaneously using ultrasonic vibration and bipolar diathermy, this device can seal and divide arteries and veins up to 7 mm in diameter .</li><li>• Thunder beat STM (Olympus)</li><li>• seal and divide arteries and veins up to 7 mm in diameter</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Advanced bipolar energy devices , incorporating feedback-sensing technology , are capable of sealing and dividing blood vessels up to 7 mm in diameter , offering a precise and controlled application of energy in surgical procedures.</li><li>➤ Advanced bipolar energy devices , incorporating feedback-sensing technology , are capable of sealing and dividing blood vessels up to 7 mm in diameter , offering a precise and controlled application of energy in surgical procedures.</li><li>➤ Advanced bipolar energy devices</li><li>➤ feedback-sensing technology</li><li>➤ capable of sealing and dividing blood vessels up to 7 mm in diameter</li><li>➤ precise and controlled application of energy in surgical procedures.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "During coagulating a bleeding vessel in laparoscopic cholecystectomy, the tip of the device accidentally touched another metal instrument causing injury to liver. This type of injury is known as?", "options": [{"label": "A", "text": "Direct coupling", "correct": true}, {"label": "B", "text": "Capacitive coupling", "correct": false}, {"label": "C", "text": "Insulation failure", "correct": false}, {"label": "D", "text": "Diathermy failure", "correct": false}], "correct_answer": "A. Direct coupling", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Direct coupling</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Capacitive coupling - Capacitive coupling is a phenomenon where electrical current is inadvertently transferred from the active instrument to adjacent conductive materials through intact insulation , due to the buildup of an electrical field . This is not the scenario described as there was direct contact.</li><li>• Option B: Capacitive coupling</li><li>• phenomenon</li><li>• electrical current is inadvertently transferred from the active instrument to adjacent conductive materials</li><li>• intact insulation</li><li>• buildup of an electrical field</li><li>• Option C: Insulation failure - Insulation failure occurs when there is a defect in the insulation material of the diathermy instrument , allowing the electrical current to leak and potentially cause burns . This is not what happened in the described situation.</li><li>• Option C: Insulation failure</li><li>• when there is a defect in the insulation material of the diathermy instrument</li><li>• electrical current to leak and potentially cause burns</li><li>• Option D: Diathermy failure - Diathermy failure refers to a malfunction of the diathermy machine itself , which was not the case according to the given information.</li><li>• Option D: Diathermy failure</li><li>• malfunction of the diathermy machine itself</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Direct coupling injury occurs in laparoscopic surgery when the active electrode of the diathermy device comes into contact with another metal instrument , which then touches the tissue , leading to unintended thermal injury.</li><li>➤ Direct coupling injury</li><li>➤ laparoscopic surgery</li><li>➤ active electrode of the diathermy device</li><li>➤ contact with another metal instrument</li><li>➤ touches the tissue</li><li>➤ unintended thermal injury.</li><li>➤ Diathermy burns are a particular hazard in laparoscopic surgery owing to a relative lack of visibility of the entire instrument. Such burns may occur by:</li><li>➤ Diathermy burns</li><li>➤ particular hazard in laparoscopic surgery owing to a relative lack of visibility</li><li>➤ Such burns may occur by:</li><li>➤ Faulty insulation of any of the laparoscopic instruments or equipment; I ntraperitoneal contact of the diathermy with another metal instrument while activating the pedal (direct coupling); Inadvertent activation of the pedal while the diathermy tip is out of the vision of the camera; Retained heat in the diathermy tip touching susceptible structures, such as the bowel.</li><li>➤ Faulty insulation of any of the laparoscopic instruments or equipment;</li><li>➤ I ntraperitoneal contact of the diathermy with another metal instrument while activating the pedal (direct coupling);</li><li>➤ ntraperitoneal contact of the diathermy with another metal instrument while activating the pedal (direct coupling);</li><li>➤ Inadvertent activation of the pedal while the diathermy tip is out of the vision of the camera;</li><li>➤ Retained heat in the diathermy tip touching susceptible structures, such as the bowel.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 113.</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 113.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Routine drain placement is suggested in all of these procedures except?", "options": [{"label": "A", "text": "Parotid surgery", "correct": false}, {"label": "B", "text": "Modified radical mastectomy", "correct": false}, {"label": "C", "text": "Esophageal surgery", "correct": false}, {"label": "D", "text": "Thyroid surgery", "correct": true}], "correct_answer": "D. Thyroid surgery", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Thyroid surgery</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A: Parotid surgery - Drain placement is often used in parotid surgery . This is due to the potential space created after removal of the parotid gland which can accumulate fluid, thus a drain can help prevent seroma formation.</li><li>• Option A: Parotid surgery</li><li>• Drain placement</li><li>• used in parotid surgery</li><li>• Option B: Modified radical mastectomy - In the case of a modified radical mastectomy, drains are typically used to prevent fluid accumulation in the axilla and the chest wall . Seroma is the most common complication after MRM.</li><li>• Option B: Modified radical mastectomy</li><li>• modified radical mastectomy, drains</li><li>• prevent fluid accumulation in the axilla and the chest wall</li><li>• Option C: Esophageal surgery - Drains are usually placed after esophageal surgery to monitor for potential leaks from the esophageal anastomosis and to drain any accumulated fluid or blood .</li><li>• Option C: Esophageal surgery</li><li>• Drains are usually placed after esophageal surgery to monitor for potential leaks from the esophageal anastomosis</li><li>• drain any accumulated fluid or blood</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Routine drain placement is generally not recommended in thyroid surgery as current evidence does not support its utility in reducing complications or improving outcomes .</li><li>➤ Routine drain placement</li><li>➤ not recommended in thyroid surgery</li><li>➤ current evidence does not support its utility in reducing complications or improving outcomes</li><li>➤ 1. Current role of drain placement in non-gastrointestinal surgery:</li><li>➤ 1. Current role of drain placement in non-gastrointestinal surgery:</li><li>➤ Avoid routine drain placement :</li><li>➤ Avoid routine drain placement</li><li>➤ Thyroid surgery Breast lumpectomy Inguinal hernia repair</li><li>➤ Thyroid surgery</li><li>➤ Breast lumpectomy</li><li>➤ Inguinal hernia repair</li><li>➤ Consider routine drain placement :</li><li>➤ Consider routine drain placement</li><li>➤ Radical and modified radical neck dissection Parotid surgery Axillary dissection with or without mastectomy Inguinal lymphadenectomy Ventral hernia repair in obese patients</li><li>➤ Radical and modified radical neck dissection</li><li>➤ Parotid surgery</li><li>➤ Axillary dissection with or without mastectomy</li><li>➤ Inguinal lymphadenectomy</li><li>➤ Ventral hernia repair in obese patients</li><li>➤ 2. Current role of drain placement in gastrointestinal surgery:</li><li>➤ 2. Current role of drain placement in gastrointestinal surgery:</li><li>➤ Avoid routine drain placement following :</li><li>➤ Avoid routine drain placement following</li><li>➤ Colonic surgery Small bowel resections Hepatic resections Cholecystectomy</li><li>➤ Colonic surgery</li><li>➤ Small bowel resections</li><li>➤ Hepatic resections</li><li>➤ Cholecystectomy</li><li>➤ Consider routine drain placement following :</li><li>➤ Consider routine drain placement following</li><li>➤ Esophageal surgery Major pancreatic resection</li><li>➤ Esophageal surgery</li><li>➤ Major pancreatic resection</li><li>➤ Selective use of drains following :</li><li>➤ Selective use of drains following</li><li>➤ Rectal surgery Gastric resections</li><li>➤ Rectal surgery</li><li>➤ Gastric resections</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 114-115.</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 114-115.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which structure separates the superficial and deep lobes of submandibular gland ?", "options": [{"label": "A", "text": "Hyoid bone", "correct": false}, {"label": "B", "text": "Posterior belly of digastric", "correct": false}, {"label": "C", "text": "Mylohyoid muscle", "correct": true}, {"label": "D", "text": "Facial nerve trunk", "correct": false}], "correct_answer": "C. Mylohyoid muscle", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/16/picture2_tnJye2n.jpg"], "explanation": "<p><strong>Ans. C) Mylohyoid muscle</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The mylohyoid muscle separates the superficial and deep lobes of the submandibular gland , with the superficial lobe situated in the digastric triangle and the deep lobe lying medial to the mylohyoid muscle .</li><li>➤ mylohyoid muscle separates</li><li>➤ superficial and deep lobes of the submandibular gland</li><li>➤ superficial lobe</li><li>➤ digastric triangle</li><li>➤ deep lobe lying medial to the mylohyoid muscle</li><li>➤ Submandibular gland anatomy :</li><li>➤ Submandibular gland anatomy</li><li>➤ They lie in the submandibular space between the digastric muscles and extend upwards deep to the mandible. They consist of a larger superficial and a smaller deep lobe that is continuous around the posterior border of the mylohyoid muscle. The deep part of the gland lies on the hyoglossus muscle in close relation to the lingual nerve. Wharton’s (submandibular) duct lies between the hyoglossus and mylohyoid muscle after arising from the deep part of the gland. It drains at the sublingual papilla into the anterior floor of the mouth (antigravity drainage)</li><li>➤ They lie in the submandibular space between the digastric muscles and extend upwards deep to the mandible.</li><li>➤ submandibular space between the digastric muscles and extend upwards deep to the mandible.</li><li>➤ They consist of a larger superficial and a smaller deep lobe that is continuous around the posterior border of the mylohyoid muscle. The deep part of the gland lies on the hyoglossus muscle in close relation to the lingual nerve.</li><li>➤ They consist of a larger superficial and a smaller deep lobe that is continuous around the posterior border of the mylohyoid muscle.</li><li>➤ lingual nerve.</li><li>➤ Wharton’s (submandibular) duct lies between the hyoglossus and mylohyoid muscle after arising from the deep part of the gland. It drains at the sublingual papilla into the anterior floor of the mouth (antigravity drainage)</li><li>➤ Wharton’s (submandibular) duct lies between the hyoglossus and mylohyoid</li><li>➤ Ref: Bailey and Love, 28 th Ed. 833</li><li>➤ Ref:</li><li>➤ Bailey and Love, 28 th Ed. 833</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old man comes to the OPD to with a painless swelling on the left side of his face. The mass is growing over several months. On examination, left sided non tender mobile pre-auricular mass extending the angle of mandible is noted. The mass obliterates the retromandibular groove and is variable in consistency. On biopsy, proliferation of ductal myoepithelial and epithelial cells with a marked increase in stromal components is seen. Which of the following is the most likely diagnosis?", "options": [{"label": "A", "text": "Mucoepidermoid carcinoma", "correct": false}, {"label": "B", "text": "Pleomorphic adenoma", "correct": true}, {"label": "C", "text": "Facial nerve schwannoma", "correct": false}, {"label": "D", "text": "Sialadenosis", "correct": false}], "correct_answer": "B. Pleomorphic adenoma", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Pleomorphic adenoma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Mucoepidermoid carcinoma - This is a type of malignant salivary gland tumor characterized by mucous and squamous cells . It typically presents as a firm, painless mass but can also be associated with pain and facial nerve involvement. The biopsy would show mucous cells, intermediate cells, and epidermoid cells, which is not consistent with the biopsy findings described.</li><li>• Option A. Mucoepidermoid carcinoma</li><li>• malignant salivary gland tumor</li><li>• mucous and squamous cells</li><li>• firm, painless mass but can also be associated with pain and facial nerve involvement.</li><li>• Option C. Facial nerve schwannoma - Schwannomas are tumors of nerve sheath origin and may present as a painless mass . However, they are associated with the cranial nerves, particularly the facial nerve , and would likely present with facial nerve dysfunction if they were large enough. The biopsy would show schwann cells, with a typical pattern of Antoni A and Antoni B areas, which is not what is described in the biopsy report.</li><li>• Option C. Facial nerve schwannoma</li><li>• tumors of nerve sheath origin and may present as a painless mass</li><li>• they are associated with the cranial nerves, particularly the facial nerve</li><li>• present with facial nerve dysfunction if they were large enough.</li><li>• Option D. Sialadenosis - Sialadenosis presents as a bilateral non tender swelling of the parotid glands usually due to nutritional disorders, hypothyroidism, cirrhosis etc . Histology reveals atrophy of parenchyma tissue and compensatory increase in adipose tissue..</li><li>• Option D. Sialadenosis</li><li>• bilateral non tender swelling of the parotid glands</li><li>• nutritional disorders, hypothyroidism, cirrhosis etc</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Pleomorphic adenoma is the most likely diagnosis for a painless, slow-growing, mobile mass in the pre-auricular area extending to the angle of the mandible in a 50-year-old man, with biopsy findings showing proliferation of ductal, myoepithelial, and epithelial cells along with a marked increase in stromal components.</li><li>➤ Pleomorphic adenoma</li><li>➤ diagnosis for a painless, slow-growing, mobile mass in the pre-auricular area extending to the angle of the mandible</li><li>➤ Pleomorphic Adenoma:</li><li>➤ Pleomorphic Adenoma:</li><li>➤ Pleomorphic adenoma is a benign tumour consisting of ductal epithelial and myoepithelial cells. The presence of both epithelial and mesenchymal differentiation defines this tumour as pleomorphic . These are the most common benign salivary gland tumours . They can occur at all ages, but are most commonly seen between the third and sixth decade. The average age of presentation is 45 years and they are more frequently seen in women. They occur most frequently in the parotid glands (&gt;80%). Presents as a painless, well-defined solitary mobile mass with gradual progression over many years and can reach enormous proportions. On HP, the tumour comprises mixed epithelial, myoepithelial and stromal components. A spectrum of architectural and cellular features is seen, including oval, epithelioid, spindle shaped, plasmacytoid and clear cells.</li><li>➤ Pleomorphic adenoma is a benign tumour consisting of ductal epithelial and myoepithelial cells. The presence of both epithelial and mesenchymal differentiation defines this tumour as pleomorphic .</li><li>➤ The presence of both epithelial and mesenchymal differentiation defines this tumour as pleomorphic</li><li>➤ These are the most common benign salivary gland tumours . They can occur at all ages, but are most commonly seen between the third and sixth decade. The average age of presentation is 45 years and they are more frequently seen in women. They occur most frequently in the parotid glands (&gt;80%).</li><li>➤ These are the most common benign salivary gland tumours</li><li>➤ They occur most frequently in the parotid glands (&gt;80%).</li><li>➤ Presents as a painless, well-defined solitary mobile mass with gradual progression over many years and can reach enormous proportions.</li><li>➤ painless, well-defined solitary mobile mass</li><li>➤ with gradual progression</li><li>➤ On HP, the tumour comprises mixed epithelial, myoepithelial and stromal components. A spectrum of architectural and cellular features is seen, including oval, epithelioid, spindle shaped, plasmacytoid and clear cells.</li><li>➤ Ref: Bailey and Love Short Practice of Surgery 28th edition page 839-840</li><li>➤ Ref:</li><li>➤ Bailey and Love Short Practice of Surgery 28th edition page 839-840</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 55 years old woman comes because of 2 weeks history of painful swelling on right side of face. USG shows a stone in a duct that runs anterior to the masseter muscle and passes through the buccinator muscle. Sialendoscopy is performed to remove the stone. At which of the following sites is the endoscope most likely to be inserted during the procedure?", "options": [{"label": "A", "text": "Lateral to the second upper molar tooth", "correct": true}, {"label": "B", "text": "Lateral to the lingual frenulum", "correct": false}, {"label": "C", "text": "In the floor of the mouth", "correct": false}, {"label": "D", "text": "In the mandibular foramen", "correct": false}], "correct_answer": "A. Lateral to the second upper molar tooth", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Lateral to the second upper molar tooth</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. Lateral to the lingual frenulum - This is the location of the submandibular gland duct , or Wharton's duct , which opens at the sublingual caruncle by the lingual frenulum .</li><li>• Option B. Lateral to the lingual frenulum</li><li>• location of the submandibular gland duct</li><li>• Wharton's duct</li><li>• sublingual caruncle by the lingual frenulum</li><li>• Option C. Into the floor of the mouth - While the floor of the mouth is the location for the openings of both the sublingual glands and the submandibular glands , it is not the correct site for a parotid duct stone.</li><li>• Option C. Into the floor of the mouth</li><li>• location for the</li><li>• openings of both the sublingual glands</li><li>• submandibular glands</li><li>• Option D. Into the mandibular foramen - The mandibular foramen is an opening on the internal surface of the ramus of the mandible for the mandibular nerve and vessels; it is not related to the salivary glands or ducts and would not be a site for sialendoscopy.</li><li>• Option D. Into the mandibular foramen</li><li>• opening on the internal surface of the ramus of the mandible for the mandibular nerve and vessels;</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ For a sialendoscopy procedure to remove a stone from the parotid duct , the endoscope is most likely to be inserted lateral to the second upper molar tooth , which is where the parotid duct opens into the oral cavity after passing through the buccinator muscle.</li><li>➤ sialendoscopy</li><li>➤ procedure</li><li>➤ remove a stone from the parotid duct</li><li>➤ endoscope is most likely to be inserted lateral to the second upper molar tooth</li><li>➤ parotid duct opens into the oral cavity</li><li>➤ Sialolithiasis: It affects the parotid gland or duct in approx. 20% of cases typically manifest with acute pain while eating and tender swelling of the affected gland, both of which are seen here. Risk factors include dehydration, certain medications like anticholinergics and trauma. The submandibular gland is most commonly affected (80-85%), owing to the ascending course of its duct, predisposing it to stagnation of the mucinous as well as the more viscous saliva it produces</li><li>➤ Sialolithiasis: It affects the parotid gland or duct in approx. 20% of cases typically manifest with acute pain while eating and tender swelling of the affected gland, both of which are seen here. Risk factors include dehydration, certain medications like anticholinergics and trauma. The submandibular gland is most commonly affected (80-85%), owing to the ascending course of its duct, predisposing it to stagnation of the mucinous as well as the more viscous saliva it produces</li><li>➤ Sialolithiasis:</li><li>➤ It affects the parotid gland or duct in approx. 20% of cases typically manifest with acute pain while eating and tender swelling of the affected gland, both of which are seen here. Risk factors include dehydration, certain medications like anticholinergics and trauma. The submandibular gland is most commonly affected (80-85%), owing to the ascending course of its duct, predisposing it to stagnation of the mucinous as well as the more viscous saliva it produces</li><li>➤ It affects the parotid gland or duct in approx. 20% of cases typically manifest with acute pain while eating and tender swelling of the affected gland, both of which are seen here.</li><li>➤ parotid gland or duct in approx. 20% of cases</li><li>➤ Risk factors include dehydration, certain medications like anticholinergics and trauma.</li><li>➤ dehydration, certain medications like anticholinergics and trauma.</li><li>➤ The submandibular gland is most commonly affected (80-85%), owing to the ascending course of its duct, predisposing it to stagnation of the mucinous as well as the more viscous saliva it produces</li><li>➤ submandibular gland is most commonly affected</li><li>➤ Ref: Scott browns otorhinolaryngology 7th edition page 1924 1925</li><li>➤ Ref:</li><li>➤ Scott browns otorhinolaryngology 7th edition page 1924 1925</li><li>➤ Bailey and Love, 28 th Ed. Pg 836-837</li><li>➤ Bailey and Love, 28 th Ed. Pg 836-837</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 25-year-old man presented with a mass on the floor of the oral cavity. The mass is trans-illuminant. What is the management?", "options": [{"label": "A", "text": "Incision and drainage", "correct": false}, {"label": "B", "text": "Aspiration", "correct": false}, {"label": "C", "text": "Excision", "correct": false}, {"label": "D", "text": "Excision with removal of ipsilateral salivary gland", "correct": true}], "correct_answer": "D. Excision with removal of ipsilateral salivary gland", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/16/picture3_zidCg4h.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. D) Excision with removal of ipsilateral salivary gland</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Incision and drainage - This approach is typically used for abscesses, which are collections of pus that need to be drained.</li><li>• Option A. Incision and drainage</li><li>• abscesses, which are collections of pus that need to be drained.</li><li>• Option B. Aspiration - Aspiration involves using a needle to remove the fluid from a cyst or mass . It can provide temporary relief but does not remove the cyst itself, which means there is a potential for recurrence.</li><li>• Option B. Aspiration</li><li>• using a needle to remove the fluid from a cyst or mass</li><li>• Option C. Excision - Complete excision is done for ranula . However, the affected sublingual gland should also be excised.</li><li>• Option C. Excision</li><li>• ranula</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective: Top of Form</li><li>➤ Bottom of Form</li><li>➤ Ranula:</li><li>➤ Ranula:</li><li>➤ It is an asymmetrical, soft and trans-illuminant swelling in the floor of the mouth . Most common between 10-30 years of age . Caused either by the rupture of the main duct or by the rupture of obstructed acini of the sublingual gland (mucous extravasation cyst). They appear as a characteristic bluish swelling in the anterior floor of the mouth and resemble the belly or air sac of a frog. They can remain localised or insinuate through the mylohyoid muscle to present as a submental swelling called a ‘plunging ranula’. They are usually soft, fluctuant and painless unless infected . Treatment should include removal of the sublingual gland as this gland has multiple ducts and ranulas can recur if the gland is left behind. Incision, drainage and marsupialisation have low success rates. Injecting OK-432 at the local site produces inflammation and fibrosis.</li><li>➤ It is an asymmetrical, soft and trans-illuminant swelling in the floor of the mouth .</li><li>➤ asymmetrical, soft and trans-illuminant swelling</li><li>➤ in the floor of the mouth</li><li>➤ Most common between 10-30 years of age .</li><li>➤ 10-30 years of age</li><li>➤ Caused either by the rupture of the main duct or by the rupture of obstructed acini of the sublingual gland (mucous extravasation cyst).</li><li>➤ They appear as a characteristic bluish swelling in the anterior floor of the mouth and resemble the belly or air sac of a frog.</li><li>➤ bluish swelling in the anterior floor of the mouth</li><li>➤ They can remain localised or insinuate through the mylohyoid muscle to present as a submental swelling called a ‘plunging ranula’.</li><li>➤ ‘plunging ranula’.</li><li>➤ They are usually soft, fluctuant and painless unless infected .</li><li>➤ soft, fluctuant and painless unless infected</li><li>➤ Treatment should include removal of the sublingual gland as this gland has multiple ducts and ranulas can recur if the gland is left behind. Incision, drainage and marsupialisation have low success rates. Injecting OK-432 at the local site produces inflammation and fibrosis.</li><li>➤ Incision, drainage and marsupialisation have low success rates.</li><li>➤ Ref: Bailey and Love Short Practice of Surgery 28th edition page 834</li><li>➤ Ref:</li><li>➤ Bailey and Love Short Practice of Surgery 28th edition page 834</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 55-year-old man was scheduled for a right parotidectomy to remove a pleomorphic adenoma involving the right parotid gland. The surgery was completed without any complications. After surgery, loss of sensations was experienced by the patient in the cheek and ear lobe while shaving. Which of the following structures was injured during this patient’s surgery?", "options": [{"label": "A", "text": "Auriculotemporal nerve", "correct": false}, {"label": "B", "text": "Buccal branch of facial nerve", "correct": false}, {"label": "C", "text": "Marginal mandibular nerve", "correct": false}, {"label": "D", "text": "Greater auricular nerve", "correct": true}], "correct_answer": "D. Greater auricular nerve", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Greater auricular nerve</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Auriculotemporal nerve - This nerve is a branch of the mandibular nerve (V3) and provides sensory innervation to the ear and temporal region . It can be affected during parotid surgery , leading to Frey's syndrome , which is characterized by sweating in the region of the cheek while eating (gustatory sweating), not numbness.</li><li>• Option A. Auriculotemporal nerve</li><li>• branch of the mandibular nerve</li><li>• provides sensory innervation</li><li>• ear and temporal region</li><li>• affected during parotid surgery</li><li>• Frey's syndrome</li><li>• sweating in the region of the cheek while eating</li><li>• Option B. Buccal branch of facial nerve - The buccal branch of the facial nerve is responsible for motor innervation to the muscles of facial expression like buccinator , particularly in the cheek region . Damage to this nerve would result in difficulty with facial movements rather than loss of sensation .</li><li>• Option B. Buccal branch of facial nerve</li><li>• facial nerve is responsible for motor innervation to the muscles of facial expression like buccinator</li><li>• cheek region</li><li>• difficulty with facial movements rather than loss of sensation</li><li>• Option C. Marginal mandibular nerve - Damage to this nerve would not lead to sensory deficits but may affect lower lip function.</li><li>• Option C. Marginal mandibular nerve</li><li>• not lead to sensory deficits but may affect lower lip function.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Injury to the greater auricular nerve during a parotidectomy can result in loss of sensation in the cheek and earlobe due to its sensory innervation to these areas .</li><li>➤ Injury</li><li>➤ greater auricular nerve</li><li>➤ parotidectomy</li><li>➤ loss of sensation</li><li>➤ cheek and earlobe</li><li>➤ sensory innervation to these areas</li><li>➤ Other complications of parotidectomy are:</li><li>➤ Other complications of parotidectomy are:</li><li>➤ Frey’s syndrome – Damage to Auriculotemporal nerve Facial nerve or its branches injury Parotid fistula Sialocele</li><li>➤ Frey’s syndrome – Damage to Auriculotemporal nerve</li><li>➤ Facial nerve or its branches injury</li><li>➤ Parotid fistula</li><li>➤ Sialocele</li><li>➤ Facial paralysis is the most important complication of parotid surgery . Temporary paralysis of the facial nerve can occur in 5% to 10% of patients and is due to the manipulation of the nerve during the surgery. The function returns gradually in a few months. Temporary facial palsy is commonly seen in the lower branches, especially the marginal mandibular nerve. Parotid duct injury during parotidectomy leads to the formation of a parotid fistula with a continuous outpouring of parotid secretions through a tract that connects the skin with the ported duct or gland. The lesion of the buccal branch of facial nerve leads to paralysis of the buccinator muscle . This causes the inability to clear food from the mouth as the food gets stuck in the cheek on the affected side. Injury to the main trunk of facial nerve leads to ipsilateral facial palsy that presents with the inability to close the eye, inability to smile and difficulty in making facial expressions. Both the upper and lower parts of the ipsilateral face are involved.</li><li>➤ Facial paralysis is the most important complication of parotid surgery . Temporary paralysis of the facial nerve can occur in 5% to 10% of patients and is due to the manipulation of the nerve during the surgery. The function returns gradually in a few months. Temporary facial palsy is commonly seen in the lower branches, especially the marginal mandibular nerve.</li><li>➤ Facial paralysis is the most important complication of parotid surgery</li><li>➤ especially the marginal mandibular nerve.</li><li>➤ Parotid duct injury during parotidectomy leads to the formation of a parotid fistula with a continuous outpouring of parotid secretions through a tract that connects the skin with the ported duct or gland.</li><li>➤ Parotid duct</li><li>➤ parotidectomy</li><li>➤ parotid fistula</li><li>➤ The lesion of the buccal branch of facial nerve leads to paralysis of the buccinator muscle . This causes the inability to clear food from the mouth as the food gets stuck in the cheek on the affected side.</li><li>➤ The lesion of the buccal branch of facial nerve leads to paralysis of the buccinator muscle</li><li>➤ Injury to the main trunk of facial nerve leads to ipsilateral facial palsy that presents with the inability to close the eye, inability to smile and difficulty in making facial expressions. Both the upper and lower parts of the ipsilateral face are involved.</li><li>➤ Ref: Bailey and Love Short practice of surgery 28th edition - page 832-833, 849.</li><li>➤ Ref:</li><li>➤ Bailey and Love Short practice of surgery 28th edition - page 832-833, 849.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 62-year-old man presented to the surgery OPD with swelling in front of the left ear since 8 months. The swelling is insidious in onset, gradually increasing in size. There is history of 20 pack year history of smoking. On examination, a firm, non-tender swelling is noted. A salivary gland tumour is suspected. Tc 99 pertechnetate scan shows a hot spot on the radionuclide scan. Which of the following is the most likely diagnosis?", "options": [{"label": "A", "text": "Adenolymphoma", "correct": true}, {"label": "B", "text": "Adenoid cystic carcinoma", "correct": false}, {"label": "C", "text": "Acinic cell tumour", "correct": false}, {"label": "D", "text": "Adenocarcinoma", "correct": false}], "correct_answer": "A. Adenolymphoma", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Adenolymphoma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. Adenoid cystic carcinoma - This is a malignant salivary gland tumor that most commonly affects the minor salivary glands , particularly the hard palate . It typically does not demonstrate a hot spot on Tc 99m pertechnetate scans.</li><li>• Option B. Adenoid cystic carcinoma</li><li>• malignant salivary gland tumor</li><li>• commonly affects the minor salivary glands</li><li>• hard palate</li><li>• Option C. Acinic cell tumour - This is a malignant tumor that arises from the acinar cells of the salivary glands , usually the parotid gland . It is typically slow-growing but does not show a hot spot on Tc 99m pertechnetate scans.</li><li>• Option C. Acinic cell tumour</li><li>• malignant tumor that arises from the acinar cells</li><li>• salivary glands</li><li>• parotid gland</li><li>• slow-growing</li><li>• Option D. Adenocarcinoma - This is a type of malignant salivary gland tumor that encompasses various histological subtypes . These tumors do not typically concentrate Tc 99m pertechnetate and therefore do not present as hot spots on the scan.</li><li>• Option D. Adenocarcinoma</li><li>• malignant salivary gland tumor</li><li>• encompasses various histological subtypes</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Adenolymphoma (Warthin's tumor) is the most likely diagnosis in a patient with a smoking history and a firm, non-tender swelling in front of the ear , especially when a Tc 99m pertechnetate scan shows a hot spot , indicative of the high mitochondrial content of oncocytes .</li><li>➤ Adenolymphoma</li><li>➤ patient with a smoking history and a firm, non-tender swelling in front of the ear</li><li>➤ Tc 99m pertechnetate scan</li><li>➤ hot spot</li><li>➤ high mitochondrial</li><li>➤ oncocytes</li><li>➤ Warthin tumour is the second most common benign parotid gland tumour - 10 to 15% of total neoplasms. It is exclusive to parotid, especially in inferior pole. Also known as adenolymphoma or cystadenoma lymphomatosum , is a benign tumour composed of oncocytic epithelial cells lining ductal, papillary and cystic spaces in a reactive lymphoid tissue Commonly seen between 5th to 7th decade and has a male predilection for occurrence - MC found in smokers Imaging for salivary gland tumours with Tc 99m pertechnetate is a useful. Modality for evaluating the functional status of salivary glands The salivary glands only neoplasm that consistently concentrate Tc -99m pertechnetate are Warthin tumour or Aden-lymphoma and oncocytoma The retention Tc 99m pertechnetate in a salivary gland during a scan is seen as a hot spot on the Tc 99m scan and is due to the high mitochondrial content in oncocytes. Rx is by enucleation/excision (unlike pleomorphic adenoma).</li><li>➤ Warthin tumour is the second most common benign parotid gland tumour - 10 to 15% of total neoplasms. It is exclusive to parotid, especially in inferior pole.</li><li>➤ Also known as adenolymphoma or cystadenoma lymphomatosum , is a benign tumour composed of oncocytic epithelial cells lining ductal, papillary and cystic spaces in a reactive lymphoid tissue</li><li>➤ Also known as adenolymphoma or cystadenoma lymphomatosum</li><li>➤ oncocytic epithelial cells lining ductal, papillary and cystic spaces</li><li>➤ Commonly seen between 5th to 7th decade and has a male predilection for occurrence - MC found in smokers</li><li>➤ MC found in smokers</li><li>➤ Imaging for salivary gland tumours with Tc 99m pertechnetate is a useful. Modality for evaluating the functional status of salivary glands</li><li>➤ The salivary glands only neoplasm that consistently concentrate Tc -99m pertechnetate are Warthin tumour or Aden-lymphoma and oncocytoma</li><li>➤ The retention Tc 99m pertechnetate in a salivary gland during a scan is seen as a hot spot on the Tc 99m scan and is due to the high mitochondrial content in oncocytes.</li><li>➤ The retention Tc 99m pertechnetate in a salivary gland during a scan is seen as a hot spot on the Tc 99m scan and is due to the high mitochondrial content in oncocytes.</li><li>➤ Rx is by enucleation/excision (unlike pleomorphic adenoma).</li><li>➤ Rx is by enucleation/excision</li><li>➤ Ref: Bailey and Love Short practice of surgery 28th edition - page 840</li><li>➤ Ref:</li><li>➤ Bailey and Love Short practice of surgery 28th edition - page 840</li><li>➤ Sabiston Textbook of Surgery 21st edition - page 807</li><li>➤ Sabiston Textbook of Surgery 21st edition - page 807</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 40 years old man presents with pain in his left lower jaw for 2 weeks. A CT of head and neck shows a stone lodged in the submandibular gland duct. Which of the following is correct regarding stones of the submandibular duct?", "options": [{"label": "A", "text": "10% of stones occur in the submandibular gland", "correct": false}, {"label": "B", "text": "Majority of submandibular stones are radiolucent", "correct": false}, {"label": "C", "text": "Most common injured nerve during submandibular gland excision is the facial nerve", "correct": false}, {"label": "D", "text": "Pain is referred to the tongue due to lingual nerve irritation", "correct": true}], "correct_answer": "D. Pain is referred to the tongue due to lingual nerve irritation", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Pain is referred to the tongue due to lingual nerve irritation</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. 10% of stones occur in the submandibular gland - This statement is incorrect . Approximately 80% of salivary stones occur in the submandibular gland , due to its longer and upward-angled duct, which makes it more prone to stone formation and retention.</li><li>• Option A. 10% of stones occur in the submandibular gland</li><li>• incorrect</li><li>• 80% of salivary stones occur in the submandibular gland</li><li>• Option B. Majority of submandibular stones are radiolucent - This statement is incorrect . Most salivary gland stones, about 80%, are radiopaque as they are usually calcium containing (CaPO4)</li><li>• Option B. Majority of submandibular stones are radiolucent</li><li>• incorrect</li><li>• 80%, are radiopaque</li><li>• Option C. Most common injured nerve during submandibular gland excision is the facial nerve This statement is incorrect . The most commonly injured nerves during submandibular gland excision are the lingual nerve and the marginal mandibular branch of the facial nerve , not the main trunk of the facial nerve.</li><li>• Option C. Most common injured nerve during submandibular gland excision is the facial nerve</li><li>• incorrect</li><li>• injured nerves during submandibular gland excision</li><li>• lingual nerve</li><li>• marginal mandibular branch of the facial nerve</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The correct statement regarding stones of the submandibular duct is that pain can be referred to the tongue due to irritation of the lingual nerve by an impacted stone.</li><li>➤ Sialolithiasis is the formation of stones in the salivary glands. About 80% of salivary stones form in the submandibular gland. They are usually formed of calcium or magnesium phosphate. Most salivary gland stones (about 80%) are radiopaque and visible on radiographs or CT scans. A stone in the submandibular gland presents intermittent pain and swelling of the submandibular region during meals. The impacted stone may irritate the lingual nerve leading to referred pain in the tongue . Sialography is the gold standard for diagnosis and involves injecting a dye into the duct of the salivary gland. It not only helps in diagnosis of sialolithiasis but also identifies any pathology in the duct. Smaller (5 mm) distal stones can be removed with endoscopy while the larger (&gt;5 mm) distal stones may require duct slitting. For an impacted stone, the transoral route is used . Intraparenchymal stones between 5 and 7 mm can be extracted endoscopically while larger stones require transoral slitting. Stones that are not palpable and not visualised endoscopically can be removed using external shock wave lithotripsy (ESWL). The lingual, marginal mandibular and hypoglossal nerves can get injured during submandibular gland excision.</li><li>➤ Sialolithiasis is the formation of stones in the salivary glands. About 80% of salivary stones form in the submandibular gland.</li><li>➤ About 80% of salivary stones form in the submandibular gland.</li><li>➤ They are usually formed of calcium or magnesium phosphate. Most salivary gland stones (about 80%) are radiopaque and visible on radiographs or CT scans.</li><li>➤ formed of calcium or magnesium phosphate. Most salivary gland stones</li><li>➤ are radiopaque</li><li>➤ A stone in the submandibular gland presents intermittent pain and swelling of the submandibular region during meals. The impacted stone may irritate the lingual nerve leading to referred pain in the tongue .</li><li>➤ intermittent pain and swelling</li><li>➤ The impacted stone may irritate the lingual nerve leading to referred pain in the tongue</li><li>➤ Sialography is the gold standard for diagnosis and involves injecting a dye into the duct of the salivary gland. It not only helps in diagnosis of sialolithiasis but also identifies any pathology in the duct.</li><li>➤ Sialography is the gold standard</li><li>➤ Smaller (5 mm) distal stones can be removed with endoscopy while the larger (&gt;5 mm) distal stones may require duct slitting.</li><li>➤ For an impacted stone, the transoral route is used . Intraparenchymal stones between 5 and 7 mm can be extracted endoscopically while larger stones require transoral slitting.</li><li>➤ For an impacted stone, the transoral route is used</li><li>➤ Stones that are not palpable and not visualised endoscopically can be removed using external shock wave lithotripsy (ESWL).</li><li>➤ The lingual, marginal mandibular and hypoglossal nerves can get injured during submandibular gland excision.</li><li>➤ Ref: Bailey and Love Short practice of surgery 28th edition - page 836-838</li><li>➤ Ref:</li><li>➤ Bailey and Love Short practice of surgery 28th edition - page 836-838</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45 years old woman presented to the surgery OPD with complaints of a slow growing painless swelling on the right side of her mouth for the past 2 years. The swelling is lobular and non-tender. Biopsy of the swelling reveals a pleomorphic adenoma. Which of the following statements is correct regarding the diagnosis of this patient?", "options": [{"label": "A", "text": "It is most common benign neoplasm of the salivary glands", "correct": true}, {"label": "B", "text": "It never undergoes malignant transformation", "correct": false}, {"label": "C", "text": "Core biopsy is needed for diagnosis", "correct": false}, {"label": "D", "text": "It can be treated by enucleation", "correct": false}], "correct_answer": "A. It is most common benign neoplasm of the salivary glands", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) It is most common benign neoplasm of the salivary glands</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. It never undergoes malignant transformation - This statement is incorrect . Pleomorphic adenoma can undergo malignant transformation , although this is considered rare. The risk of transformation increases with the duration the tumor is present.</li><li>• Option B. It never undergoes malignant transformation</li><li>• incorrect</li><li>• Pleomorphic adenoma can undergo malignant transformation</li><li>• Option C. Core biopsy is needed for diagnosis - This statement is incorrect . While a core biopsy can provide a diagnosis, fine needle aspiration (FNA) is often the first-line approach for the evaluation of salivary gland masses due to its simplicity and lower risk of complications. Core biopsy may lead to seeding the biopsy tract with tumor cells and is avoided.</li><li>• Option C. Core biopsy is needed for diagnosis</li><li>• incorrect</li><li>• fine needle aspiration</li><li>• is often the first-line approach for the evaluation of salivary gland masses</li><li>• Option D. It can be treated by enucleation - This statement is incorrect . Enucleation, or simple removal of the tumor without removing surrounding normal tissue, is not recommended for pleomorphic adenoma due to the risk of recurrence and potential for tumor spillage. The tumor shows extensions (pseudopodia) which may be left behind if enucleation is done.</li><li>• Option D. It can be treated by enucleation</li><li>• incorrect</li><li>• Enucleation, or simple removal of the tumor without removing surrounding normal tissue, is not recommended for pleomorphic adenoma</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Pleomorphic adenoma is the most common benign neoplasm of the salivary glands and should be treated with complete surgical excision (superficial parotidectomy) rather than enucleation to minimize the risk of recurrence.</li><li>➤ Pleomorphic adenoma</li><li>➤ most common benign neoplasm of the salivary glands</li><li>➤ complete surgical excision</li><li>➤ A sudden increase in size or facial nerve palsy is associated with malignant transformation, which is rare. Treatment involves surgical excision with a cuff of surrounding normal tissue, where possible, to include the pseudopods from the tumour capsule. Enucleation may result in capsular breach and tumour spillage, increasing the possibility of local recurrence; it should be avoided. “Carcinoma ex pleomorphic adenoma” (epithelial and/or myoepithelial) arises in association with primary or recurrent pleomorphic adenoma.</li><li>➤ A sudden increase in size or facial nerve palsy is associated with malignant transformation, which is rare.</li><li>➤ Treatment involves surgical excision with a cuff of surrounding normal tissue, where possible, to include the pseudopods from the tumour capsule. Enucleation may result in capsular breach and tumour spillage, increasing the possibility of local recurrence; it should be avoided.</li><li>➤ Treatment involves surgical excision</li><li>➤ “Carcinoma ex pleomorphic adenoma” (epithelial and/or myoepithelial) arises in association with primary or recurrent pleomorphic adenoma.</li><li>➤ Note: Mucoepidermoid carcinoma is the most common malignant tumour of the salivary glands in children .</li><li>➤ Note: Mucoepidermoid carcinoma is the most common malignant tumour of the salivary glands in children</li><li>➤ Ref: Bailey and Love Short practice of surgery 28th edition - page 839-842</li><li>➤ Ref:</li><li>➤ Bailey and Love Short practice of surgery 28th edition - page 839-842</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 25 yearly woman presented to the dental old for routine Orthopantomogram before a molar tooth extraction. The X-ray showed a radiolucent lesion at the angle of mandible. A diagnosis of Stafne bone cyst was made. Which of the following statements is correct regarding the diagnosis of this patient?", "options": [{"label": "A", "text": "It is minor salivary gland tumor", "correct": false}, {"label": "B", "text": "It is located above the inferior dental neuromuscular bundle", "correct": false}, {"label": "C", "text": "No treatment is required", "correct": true}, {"label": "D", "text": "It increases the risk of malignancy", "correct": false}], "correct_answer": "C. No treatment is required", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) No treatment is required</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. It is a minor salivary gland tumor - This statement is incorrect . A Stafne bone cyst is not a tumor but a developmental aberrant or ectopic salivary gland tissue, typically in mandible.</li><li>• Option A. It is a minor salivary gland tumor</li><li>• incorrect</li><li>• aberrant or ectopic salivary gland tissue, typically in mandible.</li><li>• Option B. It is located above the inferior dental neuromuscular bundle - This statement is incorrect . A Stafne bone cyst typically presents as a radiolucent lesion below the inferior alveolar nerve, not above it.</li><li>• Option B. It is located above the inferior dental neuromuscular bundle</li><li>• incorrect</li><li>• Stafne bone cyst</li><li>• radiolucent lesion</li><li>• Option D. It increases the risk of malignancy - This statement is incorrect . Stafne bone cysts do not increase the risk of malignancy.</li><li>• Option D. It increases the risk of malignancy</li><li>• incorrect</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ A Stafne bone cyst presents as an asymptomatic radiolucent lesion at the angle of the mandible , usually below the inferior dental neuromuscular bundle , and does not require treatment or pose a risk for malignancy.</li><li>➤ Stafne bone cyst</li><li>➤ asymptomatic radiolucent lesion</li><li>➤ angle of the mandible</li><li>➤ below the inferior dental neuromuscular bundle</li><li>➤ Stafne bone cyst is the most common aberrant or ectopic salivary gland tissue . The origin of this tissue has been attributed to the pulse pressure from facial artery. It presents as an asymptomatic, clearly demarcated radiolucent lesion at the angle of the mandible. It is present below the inferior dental neuromuscular bundle. No treatment is required for this condition</li><li>➤ Stafne bone cyst is the most common aberrant or ectopic salivary gland tissue . The origin of this tissue has been attributed to the pulse pressure from facial artery.</li><li>➤ Stafne bone cyst is the most common aberrant or ectopic salivary gland tissue</li><li>➤ It presents as an asymptomatic, clearly demarcated radiolucent lesion at the angle of the mandible. It is present below the inferior dental neuromuscular bundle. No treatment is required for this condition</li><li>➤ asymptomatic, clearly demarcated radiolucent lesion</li><li>➤ Ref: Bailey and Love Short practice of surgery 28 th edition - page 835</li><li>➤ Ref: Bailey and Love Short practice of surgery 28 th edition - page 835</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 58 years old man with diabetes mellitus, hypertension presents to the surgery OPD with a swelling on the left side of his face since 1 year. There is no history of fever, pain, bleeding, trismus, paresthesia or discharge from the mass. A CT scan reveals an enhancing mass in the deep lobe of the left parotid Gland. A parotid gland tumour is suspected. Which of the following is the most appropriate surgical technique for treating a benign parotid gland tumour that involves the deep lobe?", "options": [{"label": "A", "text": "Superficial parotidectomy with facial nerve preservation", "correct": false}, {"label": "B", "text": "Total parotidectomy with facial nerve sacrifice", "correct": false}, {"label": "C", "text": "Deep lobe parotidectomy with facial preservation", "correct": true}, {"label": "D", "text": "Deep lobe parotidectomy with facial nerve sacrifice", "correct": false}], "correct_answer": "C. Deep lobe parotidectomy with facial preservation", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Deep lobe parotidectomy with facial preservation</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Superficial parotidectomy with facial nerve preservation - This technique is typically used for tumors involving the superficial lobe of the parotid gland . It involves the removal of the salivary tissue lateral to the facial nerve, with the nerve being carefully preserved.</li><li>• Option A. Superficial parotidectomy with facial nerve preservation</li><li>• used for tumors involving the superficial lobe of the parotid gland</li><li>• Option B. Total parotidectomy with facial nerve sacrifice - Total parotidectomy involves the removal of the entire gland, and facial nerve sacrifice is generally considered only if the nerve is encased or infiltrated by a malignancy, which is not suggested in the given scenario.</li><li>• Option B. Total parotidectomy with facial nerve sacrifice</li><li>• removal of the entire gland, and facial nerve</li><li>• Option D. Deep lobe parotidectomy with facial nerve sacrifice - This approach is not typically necessary for benign tumors , as there is a strong preference to preserve the facial nerve unless absolutely indicated by malignancy or nerve involvement.</li><li>• Option D. Deep lobe parotidectomy with facial nerve sacrifice</li><li>• not typically necessary for benign tumors</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most appropriate surgical technique for a benign tumor involving the deep lobe of the parotid gland is deep lobe parotidectomy with facial nerve preservation.</li><li>➤ surgical technique for a benign tumor</li><li>➤ deep lobe of the parotid gland is deep lobe parotidectomy</li><li>➤ facial nerve preservation.</li><li>➤ For parotid gland tumours, depending on the involvement of the parotid lobe or the facial nerve, the following surgeries can be done:</li><li>➤ Superficial parotidectomy is done for benign tumours (pleomorphic adenoma) involving the superficial lobe. Salivary tissue lateral to the facial nerve is removed Deep lobe parotidectomy or total conservative parotidectomy is done for benign tumours involving the deep lobe Radical parotidectomy with/without facial nerve preservation is performed for malignancies of parotid.</li><li>➤ Superficial parotidectomy is done for benign tumours (pleomorphic adenoma) involving the superficial lobe. Salivary tissue lateral to the facial nerve is removed</li><li>➤ Superficial parotidectomy is done for benign tumours</li><li>➤ Deep lobe parotidectomy or total conservative parotidectomy is done for benign tumours involving the deep lobe</li><li>➤ Deep lobe parotidectomy or total conservative parotidectomy is done for benign tumours involving the deep lobe</li><li>➤ Radical parotidectomy with/without facial nerve preservation is performed for malignancies of parotid.</li><li>➤ Radical parotidectomy with/without facial nerve preservation is performed for malignancies of parotid.</li><li>➤ Ref: Bailey and Love Short practice of surgery 28th edition - page 846</li><li>➤ Ref:</li><li>➤ Bailey and Love Short practice of surgery 28th edition - page 846</li><li>➤ Sabiston Textbook of surgery 21st edition page 808</li><li>➤ Sabiston Textbook of surgery 21st edition page 808</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 60-year-old woman presents to surgery OPD with complaint of progressive, painless swelling on the right side of cheek since 6 months. Examination reveals marked facial asymmetry and eversion of right earlobe, firm swelling with no skin or facial nerve involvement. Further workup revealed that the tumour is localised to the superficial lobe therefore superficial parotidectomy is planned. Which of the following is the correct shape of incision for superficial parotidectomy?", "options": [{"label": "A", "text": "L shaped", "correct": false}, {"label": "B", "text": "Y shaped", "correct": false}, {"label": "C", "text": "S shaped", "correct": true}, {"label": "D", "text": "Z shaped", "correct": false}], "correct_answer": "C. S shaped", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/16/picture4_QxxxqoI.jpg"], "explanation": "<p><strong>Ans. C) S shaped</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. L shaped incision is used in surgeries of the abdomen, thorax and plastic surgeries .</li><li>• Option A. L shaped incision</li><li>• surgeries of the abdomen, thorax and plastic surgeries</li><li>• Option B. Y shaped incision is given postmortem examination or autopsies .</li><li>• Option B. Y shaped incision</li><li>• postmortem examination or autopsies</li><li>• Option D. Z shaped incision are given in plastic surgeries to improve the cosmetic appearance of scars .</li><li>• Option D. Z shaped incision</li><li>• plastic surgeries to improve the cosmetic appearance of scars</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ The correct incision for a superficial parotidectomy is an S-shaped incision , also known as a 'Blair' or 'lazy S' incision , which provides appropriate exposure for the surgery while following the natural skin creases for better cosmetic results.</li><li>➤ correct incision</li><li>➤ superficial parotidectomy is an S-shaped incision</li><li>➤ 'Blair' or 'lazy S' incision</li><li>➤ Ref: Bailey and Love Short practice of surgery 28th edition - page 846</li><li>➤ Ref: Bailey and Love Short practice of surgery 28th edition - page 846</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 30-year-old woman presents with sweating, flushing and burning sensation on her left cheek after eating spicy or sour foods. She has a history some surgery below the ear for a tumor 1 year back. The patient is asked to eat a lemon and a diffuse erythema on her left cheek develops after eating the lemon. Minors’ iodine starch test revealed localised hyperhidrosis over the left zygomatic arch. Which of the following nerves is the commonly involved in the pathophysiology of the patents condition?", "options": [{"label": "A", "text": "Facial nerve", "correct": false}, {"label": "B", "text": "Trigeminal nerve", "correct": false}, {"label": "C", "text": "Auriculotemporal nerve", "correct": true}, {"label": "D", "text": "Glossopharyngeal nerve", "correct": false}], "correct_answer": "C. Auriculotemporal nerve", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Auriculotemporal nerve</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Facial nerve - The facial nerve is primarily a motor nerve that controls the muscles of facial expression. While it can be affected during parotid gland surgery, it is not typically associated with postoperative gustatory sweating.</li><li>• Option A. Facial nerve</li><li>• motor nerve that controls the muscles of facial expression.</li><li>• not typically associated with postoperative gustatory sweating.</li><li>• Option B. Trigeminal nerve - The trigeminal nerve is primarily responsible for facial sensation and motor function for mastication . It is not typically implicated in gustatory sweating.</li><li>• Option B. Trigeminal nerve</li><li>• facial sensation and motor function for mastication</li><li>• Option D. Glossopharyngeal nerve - The glossopharyngeal nerve provides sensory innervation to the pharynx and back of the tongue and contributes to the parasympathetic supply to the parotid gland via the otic ganglion , but it is not directly involved in Frey's syndrome.</li><li>• Option D. Glossopharyngeal nerve</li><li>• sensory innervation to the pharynx and back of the tongue</li><li>• contributes to the parasympathetic supply to the parotid gland</li><li>• otic ganglion</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Auriculotemporal nerve provides a post-ganglionic parasympathetic supply to the parotid gland . This nerve can get transected during surgeries of the parotid gland or the mandible Frey’s syndrome (gustatory sweating) results from cross-innervation of the dermal sweat glands by the regenerating postganglionic parasympathetic nerve fibres of the auriculotemporal nerve. It occurs in most patients but is often not significant; patients rarely mention it unless it is excessive. Common presentations are sweating and flushing in the preauricular region during meals . Minor’s starch iodine test identifies the region affected . In this, iodine is painted in the preauricular region, dried and covered with starch. Salivary stimulation causes sweating, which turns the starch blue. Frey’s syndrome can be reduced either by raising a thick flap with all subcutaneous fat over the parotid or by interposition of tissue, such as a sternocleidomastoid flap, temporalis fascia, alloderm tissue or autologous fat between the skin and the surgical bed. Its incidence can be reduced by extracapsular dissection and careful closure of the superficial Musculo-aponeurotic system. Treatment includes use of antiperspirants in mild cases; in more severe cases, tympanic neurectomy or botulinum toxin injection at the site of perspiration is used, which is very effective.</li><li>➤ The Auriculotemporal nerve provides a post-ganglionic parasympathetic supply to the parotid gland .</li><li>➤ Auriculotemporal nerve</li><li>➤ parasympathetic supply to the parotid gland</li><li>➤ This nerve can get transected during surgeries of the parotid gland or the mandible</li><li>➤ Frey’s syndrome (gustatory sweating) results from cross-innervation of the dermal sweat glands by the regenerating postganglionic parasympathetic nerve fibres of the auriculotemporal nerve.</li><li>➤ Frey’s syndrome (gustatory sweating)</li><li>➤ It occurs in most patients but is often not significant; patients rarely mention it unless it is excessive.</li><li>➤ Common presentations are sweating and flushing in the preauricular region during meals .</li><li>➤ Common presentations are sweating and flushing in the preauricular region during meals</li><li>➤ Minor’s starch iodine test identifies the region affected . In this, iodine is painted in the preauricular region, dried and covered with starch. Salivary stimulation causes sweating, which turns the starch blue.</li><li>➤ Minor’s starch iodine test identifies the region affected</li><li>➤ Salivary stimulation causes sweating, which turns the starch blue.</li><li>➤ Frey’s syndrome can be reduced either by raising a thick flap with all subcutaneous fat over the parotid or by interposition of tissue, such as a sternocleidomastoid flap, temporalis fascia, alloderm tissue or autologous fat between the skin and the surgical bed. Its incidence can be reduced by extracapsular dissection and careful closure of the superficial Musculo-aponeurotic system.</li><li>➤ Frey’s syndrome can be reduced either by raising a thick flap with all subcutaneous fat over the parotid or by interposition of tissue, such as a sternocleidomastoid flap, temporalis fascia, alloderm tissue or autologous fat between the skin and the surgical bed. Its incidence can be reduced by extracapsular dissection</li><li>➤ Treatment includes use of antiperspirants in mild cases; in more severe cases, tympanic neurectomy or botulinum toxin injection at the site of perspiration is used, which is very effective.</li><li>➤ Treatment</li><li>➤ Ref: Bailey and Love Short practice of surgery 28th edition - page 848-849</li><li>➤ Ref: Bailey and Love Short practice of surgery 28th edition - page 848-849</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is the appropriate management of Frey’s syndrome?", "options": [{"label": "A", "text": "Botulinum toxin", "correct": true}, {"label": "B", "text": "Temporalis fascia flap", "correct": false}, {"label": "C", "text": "Sternocleidomastoid flap", "correct": false}, {"label": "D", "text": "Superficial parotidectomy", "correct": false}], "correct_answer": "A. Botulinum toxin", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Botulinum toxin</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. Temporalis fascia flap - While a temporalis fascia flap can be interposed during parotid surgery to prevent Frey's syndrome , it is not typically used as a management strategy after the syndrome has developed.</li><li>• Option B. Temporalis fascia flap</li><li>• interposed during parotid surgery to prevent Frey's syndrome</li><li>• Option C. Sternocleidomastoid flap - Similar to the temporalis fascia flap, a sternocleidomastoid (SCM) flap can be used during initial surgery to prevent Frey's syndrome by creating a barrier between the skin and the parotid bed. It is not a treatment for established Frey's syndrome.</li><li>• Option C. Sternocleidomastoid flap</li><li>• temporalis fascia flap, a sternocleidomastoid</li><li>• flap can be used during initial surgery to prevent Frey's syndrome</li><li>• Option D: Superficial parotidectomy - Superficial parotidectomy is a surgical procedure that may cause Frey's syndrome as a complication , and therefore, it is not a treatment for the syndrome itself.</li><li>• Option D: Superficial parotidectomy</li><li>• surgical procedure that may cause Frey's syndrome as a complication</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The appropriate management for symptomatic Frey's syndrome is the use of botulinum toxin injections , which are effective in reducing the sweating and flushing associated with the condition. Temporalis flap and SCM flaps can prevent Frey’s syndrome.</li><li>➤ appropriate management for symptomatic Frey's syndrome</li><li>➤ use of botulinum toxin injections</li><li>➤ effective in reducing the sweating and flushing associated with the condition.</li><li>➤ The auriculotemporal nerve is a branch of the glossopharyngeal nerve and provides a parasympathetic supply to the parotid gland This nerve can get transected during surgeries of the parotid gland or the mandible Stimulation of the sweat glands occurs due to taste and smell of food causing flushing, burning, erythema and sweating Frey’s syndrome can be treated by antiperspirants, botulinum toxin injections or tympanic neurectomy. Temporalis fascia flaps can be made during parotidectomy to minimise the regeneration of autonomic nerve fibres. SCM flap replaces the barrier between the skin and parotid bed to minimise the inappropriate regeneration of autonomic nerve fibres. It is used in the prevention of Frey’s syndrome and not in the management of it. Superficial parotidectomy is a cause of Frey’s syndrome and is not used for management of this syndrome.</li><li>➤ The auriculotemporal nerve is a branch of the glossopharyngeal nerve and provides a parasympathetic supply to the parotid gland</li><li>➤ auriculotemporal nerve</li><li>➤ branch of the glossopharyngeal nerve</li><li>➤ provides a parasympathetic supply to the parotid gland</li><li>➤ This nerve can get transected during surgeries of the parotid gland or the mandible</li><li>➤ Stimulation of the sweat glands occurs due to taste and smell of food causing flushing, burning, erythema and sweating</li><li>➤ Frey’s syndrome can be treated by antiperspirants, botulinum toxin injections or tympanic neurectomy.</li><li>➤ Temporalis fascia flaps can be made during parotidectomy to minimise the regeneration of autonomic nerve fibres.</li><li>➤ Temporalis fascia flaps can be made during parotidectomy to minimise the regeneration of autonomic nerve fibres.</li><li>➤ SCM flap replaces the barrier between the skin and parotid bed to minimise the inappropriate regeneration of autonomic nerve fibres. It is used in the prevention of Frey’s syndrome and not in the management of it.</li><li>➤ Superficial parotidectomy is a cause of Frey’s syndrome and is not used for management of this syndrome.</li><li>➤ Superficial parotidectomy is a cause of Frey’s syndrome and is not used for management of this syndrome.</li><li>➤ Ref: Bailey and Love Short practice of surgery 28th edition - page 846-847</li><li>➤ Ref:</li><li>➤ Bailey and Love Short practice of surgery 28th edition - page 846-847</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of these are true regarding facial nerve injury and identification in parotid surgery except?", "options": [{"label": "A", "text": "Lies superior to posterior belly of digastric", "correct": false}, {"label": "B", "text": "The upper branches are likely to get injured", "correct": true}, {"label": "C", "text": "Conley pointer lies above the facial nerve trunk", "correct": false}, {"label": "D", "text": "Extra-capsular dissection reduces the risk of injury", "correct": false}], "correct_answer": "B. The upper branches are likely to get injured", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) The upper branches are likely to get injured</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Lies superior to posterior belly of digastric - The facial nerve can be identified above the upper border of the posterior belly of the digastric muscle during parotid surgery . This is a true statement and a reliable landmark for identifying the nerve.</li><li>• Option A. Lies superior to posterior belly of digastric</li><li>• facial nerve</li><li>• identified above the upper border of the posterior belly of the digastric muscle during parotid surgery</li><li>• Option C. Conley pointer lies above the facial nerve trunk - The Conley’s pointer , or tragal pointer , is a landmark used to identify the facial nerve during surgery . It is true that the facial nerve lies approximately 1 cm deep and inferior to the tip of the tragal cartilage.</li><li>• Option C. Conley pointer lies above the facial nerve trunk</li><li>• Conley’s pointer</li><li>• tragal pointer</li><li>• landmark used to identify the facial nerve during surgery</li><li>• Option D. Extra-capsular dissection reduces the risk of injury - Extracapsular dissection for select benign parotid tumors is a technique used to avoid facial nerve dissection and therefore reduce the risk of nerve injury . This is a true statement.</li><li>• Option D. Extra-capsular dissection reduces the risk of injury</li><li>• benign parotid tumors is a technique used to avoid facial nerve dissection</li><li>• reduce the risk of nerve injury</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most common injury in parotid surgery occurs to the lower branches of the facial nerve , especially the marginal mandibular branch , not the upper branches . Identification and protection of the facial nerve are crucial during parotid surgery to prevent nerve injury. Extracapsular dissection can reduce the risk of such injuries.</li><li>➤ common injury in parotid surgery</li><li>➤ lower branches of the facial nerve</li><li>➤ marginal mandibular branch</li><li>➤ not the upper branches</li><li>➤ Temporary facial palsy is commonly seen in the lower branches, especially the marginal mandibular nerve. Most patients tend to recover over time. Identification of facial nerve: Tragal (Conley’s) pointer: the facial nerve lies 1 cm deep and inferior to the tip of the tragal cartilage ; Digastric muscle: the facial nerve can be identified above the upper border of the posterior belly of the digastric muscle; Tympano-mastoid suture: the facial nerve lies inferior to this suture line as it overlies the stylomastoid foramen . Identification of the facial trunk by a retrograde dissection technique is useful in revision cases with altered anatomy and fibrosis. It relies on the identification of one of the main branches of the nerve (usually the buccal branch in relation to the parotid duct), which is then traced proximally to the main trunk. Extracapsular dissection for select benign parotid tumours is practiced to avoid facial nerve dissection. It is reported to be as safe as parotidectomy. The tumour is dissected carefully in an extracapsular plane , visualizing the facial nerve branches. Use of intraoperative nerve monitoring makes this safer.</li><li>➤ Temporary facial palsy is commonly seen in the lower branches, especially the marginal mandibular nerve. Most patients tend to recover over time.</li><li>➤ Identification of facial nerve: Tragal (Conley’s) pointer: the facial nerve lies 1 cm deep and inferior to the tip of the tragal cartilage ; Digastric muscle: the facial nerve can be identified above the upper border of the posterior belly of the digastric muscle; Tympano-mastoid suture: the facial nerve lies inferior to this suture line as it overlies the stylomastoid foramen . Identification of the facial trunk by a retrograde dissection technique is useful in revision cases with altered anatomy and fibrosis. It relies on the identification of one of the main branches of the nerve (usually the buccal branch in relation to the parotid duct), which is then traced proximally to the main trunk.</li><li>➤ Identification of facial nerve:</li><li>➤ Tragal (Conley’s) pointer: the facial nerve lies 1 cm deep and inferior to the tip of the tragal cartilage ; Digastric muscle: the facial nerve can be identified above the upper border of the posterior belly of the digastric muscle; Tympano-mastoid suture: the facial nerve lies inferior to this suture line as it overlies the stylomastoid foramen . Identification of the facial trunk by a retrograde dissection technique is useful in revision cases with altered anatomy and fibrosis. It relies on the identification of one of the main branches of the nerve (usually the buccal branch in relation to the parotid duct), which is then traced proximally to the main trunk.</li><li>➤ Tragal (Conley’s) pointer: the facial nerve lies 1 cm deep and inferior to the tip of the tragal cartilage ;</li><li>➤ Tragal (Conley’s) pointer:</li><li>➤ facial nerve lies 1 cm deep and inferior to the tip of the tragal cartilage</li><li>➤ Digastric muscle: the facial nerve can be identified above the upper border of the posterior belly of the digastric muscle;</li><li>➤ Digastric muscle:</li><li>➤ above the upper border of the posterior belly of the digastric muscle;</li><li>➤ Tympano-mastoid suture: the facial nerve lies inferior to this suture line as it overlies the stylomastoid foramen .</li><li>➤ Tympano-mastoid suture:</li><li>➤ inferior to this suture line as it overlies the stylomastoid foramen</li><li>➤ Identification of the facial trunk by a retrograde dissection technique is useful in revision cases with altered anatomy and fibrosis. It relies on the identification of one of the main branches of the nerve (usually the buccal branch in relation to the parotid duct), which is then traced proximally to the main trunk.</li><li>➤ Extracapsular dissection for select benign parotid tumours is practiced to avoid facial nerve dissection. It is reported to be as safe as parotidectomy.</li><li>➤ Extracapsular dissection</li><li>➤ benign parotid tumours</li><li>➤ parotidectomy.</li><li>➤ The tumour is dissected carefully in an extracapsular plane , visualizing the facial nerve branches. Use of intraoperative nerve monitoring makes this safer.</li><li>➤ dissected</li><li>➤ extracapsular plane</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 846 and 848.</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 846 and 848.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is incorrect about branchial fistula?", "options": [{"label": "A", "text": "The external opening is in upper half of anterior sternocleidomastoid (SCM) muscle", "correct": true}, {"label": "B", "text": "The internal opening is in front of posterior tonsillar pillar", "correct": false}, {"label": "C", "text": "The tract passes above carotid artery bifurcation", "correct": false}, {"label": "D", "text": "Treat is complete excision of the tract", "correct": false}], "correct_answer": "A. The external opening is in upper half of anterior sternocleidomastoid (SCM) muscle", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) The external opening is in upper half of anterior SCM muscle</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. The internal opening is in front of posterior tonsillar pillar - This is correct . The internal orifice of a second branchial fistula usually opens internally on the lateral pharyngeal wall, anterior to the posterior tonsillar pillar.</li><li>• Option B. The internal opening is in front of posterior tonsillar pillar</li><li>• correct</li><li>• Option C. The tract passes above carotid artery bifurcation - This is also correct . The tract of a second branchial fistula typically passes between the internal and external carotid arteries, above the bifurcation of the common carotid artery.</li><li>• Option C. The tract passes above carotid artery bifurcation</li><li>• correct</li><li>• Option D. Treat is complete excision of the tract - This is correct . The standard treatment for a branchial fistula is complete surgical excision of the tract to prevent recurrence and resolve the symptoms.</li><li>• Option D. Treat is complete excision of the tract</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The incorrect statement about branchial fistula is that the external opening is in the upper half of the anterior sternocleidomastoid muscle ; in reality, it is typically located in the lower third of the neck along the anterior border of the muscle (junction of middle and lower third). Complete excision of the tract is necessary for treatment to avoid recurrence.</li><li>➤ incorrect statement about branchial fistula</li><li>➤ external opening is in the upper half of the anterior sternocleidomastoid muscle</li><li>➤ located in the lower third of the neck along the anterior border of the muscle</li><li>➤ A branchial fistula may be unilateral or bilateral and is thought to represent a persistent second branchial cleft. The external orifice is nearly always situated in the lower third of the neck near the anterior border of the sternocleidomastoid muscle, while the internal orifice is located on the anterior aspect of the posterior faucial pillar just behind the tonsil. Although the anterior aspect of the tract is easy to dissect, it may pass backwards and upwards through the bifurcation of the common carotid artery. The tract is lined by ciliated columnar epithelium and, as such, there may be a small amount of recurrent mucopurulent discharge onto the neck. The tract follows the same path as a branchial cyst and requires complete excision to avoid recurrence. A branchial cyst develops from the vestigial remnants of the second branchial cleft, is lined by squamous epithelium and contains thick, turbid fluid. The cyst usually presents in the upper neck in early or middle adulthood and is found at the junction of the upper third and middle third of the sternomastoid muscle at its anterior border . It is a fluctuant swelling that may transilluminate. Ultrasound and fine-needle aspiration aid both diagnosis and treatment by complete excision.</li><li>➤ A branchial fistula may be unilateral or bilateral and is thought to represent a persistent second branchial cleft.</li><li>➤ The external orifice is nearly always situated in the lower third of the neck near the anterior border of the sternocleidomastoid muscle, while the internal orifice is located on the anterior aspect of the posterior faucial pillar just behind the tonsil.</li><li>➤ lower third of the neck near the anterior border of the sternocleidomastoid</li><li>➤ Although the anterior aspect of the tract is easy to dissect, it may pass backwards and upwards through the bifurcation of the common carotid artery.</li><li>➤ The tract is lined by ciliated columnar epithelium and, as such, there may be a small amount of recurrent mucopurulent discharge onto the neck.</li><li>➤ The tract is lined by ciliated columnar epithelium</li><li>➤ The tract follows the same path as a branchial cyst and requires complete excision to avoid recurrence.</li><li>➤ A branchial cyst develops from the vestigial remnants of the second branchial cleft, is lined by squamous epithelium and contains thick, turbid fluid.</li><li>➤ The cyst usually presents in the upper neck in early or middle adulthood and is found at the junction of the upper third and middle third of the sternomastoid muscle at its anterior border . It is a fluctuant swelling that may transilluminate.</li><li>➤ found at the</li><li>➤ junction of the upper third and middle third of the sternomastoid muscle</li><li>➤ at its anterior border</li><li>➤ Ultrasound and fine-needle aspiration aid both diagnosis and treatment by complete excision.</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 805</li><li>➤ Ref:</li><li>➤ Bailey and Love, 28 th Ed. Pg 805</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year male living in a high-altitude region presents with a slow growing neck swelling in front of sternocleidomastoid (SCM) muscle. Examination reveals it to be firm, rubbery, with lateral mobility alone. The swelling is pulsatile. Which of these is not performed in the management?", "options": [{"label": "A", "text": "USG of neck", "correct": false}, {"label": "B", "text": "CT Angiogram", "correct": false}, {"label": "C", "text": "FNAC", "correct": true}, {"label": "D", "text": "Excision", "correct": false}], "correct_answer": "C. FNAC", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) FNAC</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: USG of neck - Ultrasonography (USG) of the neck is a common initial imaging modality used to evaluate neck masses . It can provide information about the nature, size, and relation to adjacent structures of the swelling.</li><li>• Option A: USG of neck</li><li>• Ultrasonography</li><li>• neck is a common initial imaging modality used to evaluate neck masses</li><li>• Option B: CT Angiogram - A CT angiogram is an essential diagnostic tool for Carotid body tumors as it can help delineate the vascular anatomy , splaying of the carotid bifurcation (Lyre sign), and relationship of the tumor to the carotid vessels.</li><li>• Option B: CT Angiogram</li><li>• essential diagnostic tool for Carotid body tumors</li><li>• help delineate the vascular anatomy</li><li>• Option D. Excision - Surgical excision is the treatment of choice for Carotid body tumors, particularly in cases where the tumor is resectable. The Shamblin classification helps determine the surgical approach and the extent of resection.</li><li>• Option D. Excision</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The management of a Carotid body tumor involves imaging studies such as USG and CT angiogram to evaluate the lesion and plan treatment , but FNAC is contraindicated due to the risk of bleeding and tumor cell dissemination. Surgical excision is the definitive treatment, tailored according to the tumor’s classification and involvement with carotid vessels.</li><li>➤ management of a Carotid body tumor</li><li>➤ imaging studies such as USG and CT angiogram</li><li>➤ lesion and plan treatment</li><li>➤ This is a rare tumour that has a higher incidence in areas where people live at high altitudes because of chronic hypoxia leading to carotid body hyperplasia . The tumours most commonly present in the fifth decade. There is an association with phaeochromocytoma in familial cases. The tumours arise from the chemoreceptor cells on the medial side of the carotid bulb and, at this point, the tumour is adherent to the carotid wall. There is often a long history of a slowly enlarging, painless lump at the carotid bifurcation . About one-third of patients present with a pharyngeal mass that pushes the tonsil medially and anteriorly. The mass is firm, rubbery, pulsatile, mobile from side to side but not up and down and can sometimes be emptied by firm pressure, after which it slowly refills in a pulsatile manner. A bruit may also be present. A carotid angiogram can be carried out to demonstrate the carotid bifurcation, which is usually splayed (Lyre sign) and a blush, which outlines the tumour vessels. MRI scanning also provides excellent detail in most cases. This tumour must not be biopsied and fine-needle aspiration is also contraindicated, The Shamblin classification is used to determine the surgical resectability of these tumours. Type I tumours are localised and do not involve more than 180° of the carotid vessels; type II tumours surround the vessel by over 180°; and type III tumours completely encase the vessels and are more challenging to resect with higher complications and a possible need for vessel reconstruction. In some cases, it may be possible to dissect the tumour away from the carotid bifurcation but, at times, when the tumour is large, it may not be separable from the vessels and resection will be necessary, such that all appropriate facilities should be available to establish a bypass while a vein autograft is inserted to restore arterial continuity in the carotid system.</li><li>➤ This is a rare tumour that has a higher incidence in areas where people live at high altitudes because of chronic hypoxia leading to carotid body hyperplasia . The tumours most commonly present in the fifth decade. There is an association with phaeochromocytoma in familial cases.</li><li>➤ higher incidence in areas where</li><li>➤ people live at high altitudes</li><li>➤ because of chronic hypoxia leading to carotid body hyperplasia</li><li>➤ The tumours arise from the chemoreceptor cells on the medial side of the carotid bulb and, at this point, the tumour is adherent to the carotid wall.</li><li>➤ arise from the chemoreceptor cells on the medial side</li><li>➤ of the carotid bulb</li><li>➤ There is often a long history of a slowly enlarging, painless lump at the carotid bifurcation .</li><li>➤ painless lump at the carotid bifurcation</li><li>➤ About one-third of patients present with a pharyngeal mass that pushes the tonsil medially and anteriorly.</li><li>➤ The mass is firm, rubbery, pulsatile, mobile from side to side but not up and down and can sometimes be emptied by firm pressure, after which it slowly refills in a pulsatile manner. A bruit may also be present.</li><li>➤ A carotid angiogram can be carried out to demonstrate the carotid bifurcation, which is usually splayed (Lyre sign) and a blush, which outlines the tumour vessels. MRI scanning also provides excellent detail in most cases. This tumour must not be biopsied and fine-needle aspiration is also contraindicated,</li><li>➤ (Lyre sign)</li><li>➤ This tumour must not be biopsied and fine-needle aspiration is also contraindicated,</li><li>➤ The Shamblin classification is used to determine the surgical resectability of these tumours. Type I tumours are localised and do not involve more than 180° of the carotid vessels; type II tumours surround the vessel by over 180°; and type III tumours completely encase the vessels and are more challenging to resect with higher complications and a possible need for vessel reconstruction.</li><li>➤ Shamblin classification is used to determine the surgical resectability</li><li>➤ type III tumours completely encase the vessels and are more challenging to resect with higher complications and a possible need for vessel reconstruction.</li><li>➤ In some cases, it may be possible to dissect the tumour away from the carotid bifurcation but, at times, when the tumour is large, it may not be separable from the vessels and resection will be necessary, such that all appropriate facilities should be available to establish a bypass while a vein autograft is inserted to restore arterial continuity in the carotid system.</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 809-810.</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 809-810.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}]; if (!Array.isArray(questions) || questions.length === 0) { throw new Error("Questions data is empty or invalid"); } debugLog(`Successfully parsed ${questions.length} questions`); } catch (e) { console.error("Failed to parse questions_json:", e); document.getElementById('error-message').innerHTML = "Error loading quiz data. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('start-test').disabled = true; // Fallback to sample questions for testing questions = [ { text: "What is 2 + 2?", options: [ { label: "A", text: "3", correct: false }, { label: "B", text: "4", correct: true }, { label: "C", text: "5", correct: false }, { label: "D", text: "6", correct: false } ], correct_answer: "B. 4", question_images: [], explanation_images: [], explanation: "<p>2 + 2 = 4</p><p>@dams_new_robot</p>", bot: "@dams_new_robot", audio: "", video: "" } ]; debugLog("Loaded fallback questions"); } // Quiz state let currentQuestion = 0; let answers = new Array(questions.length).fill(null); let markedForReview = new Array(questions.length).fill(false); let timeRemaining = 88 * 60; // Duration in seconds let timerInterval = null; const quizId = `{title.replace(/\s+/g, '_').toLowerCase()}`; // Unique ID for local storage // Load saved progress function loadProgress() { try { debugLog("Loading progress from localStorage"); const saved = localStorage.getItem(`quiz_${quizId}`); if (saved) { const { savedAnswers, savedMarked, savedTime } = JSON.parse(saved); answers = savedAnswers || answers; markedForReview = savedMarked || markedForReview; timeRemaining = savedTime !== undefined ? savedTime : timeRemaining; debugLog("Progress loaded successfully"); } else { debugLog("No saved progress found"); } } catch (e) { console.error("Error loading progress:", e); debugLog("Failed to load progress: " + e.message); } } // Save progress function saveProgress() { try { debugLog("Saving progress to localStorage"); localStorage.setItem(`quiz_${quizId}`, JSON.stringify({ savedAnswers: answers, savedMarked: markedForReview, savedTime: timeRemaining })); debugLog("Progress saved successfully"); } catch (e) { console.error("Error saving progress:", e); debugLog("Failed to save progress: " + e.message); } } // Initialize quiz function initQuiz() { try { debugLog("Initializing quiz"); loadProgress(); const startButton = document.getElementById('start-test'); if (!startButton) { throw new Error("Start test button not found"); } startButton.addEventListener('click', startQuiz); debugLog("Start test button listener attached"); document.getElementById('previous-btn').addEventListener('click', showPreviousQuestion); document.getElementById('next-btn').addEventListener('click', showNextQuestion); document.getElementById('mark-review').addEventListener('click', toggleMarkForReview); document.getElementById('nav-toggle').addEventListener('click', toggleNavPanel); document.getElementById('submit-test').addEventListener('click', showSubmitModal); document.getElementById('continue-test').addEventListener('click', closeExitModal); document.getElementById('exit-test').addEventListener('click', () => { debugLog("Exiting test"); localStorage.removeItem(`quiz_${quizId}`); window.location.reload(); }); document.getElementById('cancel-submit').addEventListener('click', closeSubmitModal); document.getElementById('confirm-submit').addEventListener('click', submitTest); document.getElementById('take-again').addEventListener('click', () => { debugLog("Restarting test"); localStorage.removeItem(`quiz_${quizId}`); window.location.reload(); }); document.getElementById('review-test').addEventListener('click', () => showResults(currentResultQuestion)); document.getElementById('close-nav').addEventListener('click', toggleNavPanel); document.getElementById('theme-toggle').addEventListener('click', toggleTheme); document.getElementById('nav-filter').addEventListener('change', updateNavPanel); document.getElementById('prev-result').addEventListener('click', showPreviousResult); document.getElementById('next-result').addEventListener('click', showNextResult); document.getElementById('results-nav-toggle').addEventListener('click', toggleResultsNavPanel); document.getElementById('close-results-nav').addEventListener('click', toggleResultsNavPanel); document.getElementById('results-nav-filter').addEventListener('change', updateResultsNavPanel); debugLog("Quiz initialized successfully"); } catch (e) { console.error("Failed to initialize quiz:", e); debugLog("Failed to initialize quiz: " + e.message); document.getElementById('error-message').innerHTML = "Error initializing quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('start-test').disabled = true; } } // Start quiz function startQuiz() { try { debugLog("Starting quiz"); document.getElementById('instructions').classList.add('hidden'); document.getElementById('quiz').classList.remove('hidden'); showQuestion(currentQuestion); startTimer(); updateNavPanel(); debugLog("Quiz started successfully"); } catch (e) { console.error("Error starting quiz:", e); debugLog("Failed to start quiz: " + e.message); document.getElementById('error-message').innerHTML = "Error starting quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('quiz').classList.add('hidden'); document.getElementById('instructions').classList.remove('hidden'); } } // Show question function showQuestion(index) { try { debugLog(`Showing question ${index + 1}`); currentQuestion = index; const q = questions[index]; if (!q) { throw new Error(`Question ${index} is undefined`); } document.getElementById('question-number').innerHTML = `Question <span>${index + 1}</span> of ${questions.length}`; document.getElementById('question-text').innerHTML = q.text || "No question text available"; const imagesDiv = document.getElementById('question-images'); imagesDiv.innerHTML = q.question_images && q.question_images.length > 0 ? q.question_images.map(url => `<img src="${url}" alt="Question Image" class="max-w-full h-auto rounded-lg">`).join('') : ''; const optionsDiv = document.getElementById('options'); optionsDiv.innerHTML = q.options && q.options.length > 0 ? q.options.map(opt => ` <button class="option-btn w-full text-left p-3 border rounded-lg ${answers[index] === opt.label ? 'selected' : ''}" onclick="selectOption(${index}, '${opt.label}')" aria-label="Option ${opt.label}: ${opt.text}"> ${opt.label}. ${opt.text} </button> `).join('') : '<p class="text-red-500">No options available</p>'; document.getElementById('previous-btn').disabled = index === 0; document.getElementById('next-btn').disabled = index === questions.length - 1; document.getElementById('mark-review').classList.toggle('marked', markedForReview[index]); updateProgressBar(); saveProgress(); window.scrollTo({ top: 0, behavior: 'smooth' }); debugLog(`Question ${index + 1} displayed successfully`); } catch (e) { console.error("Error displaying question:", e); debugLog("Failed to display question: " + e.message); } } // Select option function selectOption(index, label) { try { debugLog(`Selecting option ${label} for question ${index + 1}`); answers[index] = label; const optionsDiv = document.getElementById('options'); const optionButtons = optionsDiv.querySelectorAll('.option-btn'); optionButtons.forEach(btn => { const btnLabel = btn.textContent.trim().split('.')[0]; btn.classList.toggle('selected', btnLabel === label); }); updateNavPanel(); saveProgress(); debugLog(`Option ${label} selected for question ${index + 1}`); } catch (e) { console.error("Error selecting option:", e); debugLog("Failed to select option: " + e.message); } } // Toggle mark for review function toggleMarkForReview() { try { debugLog(`Toggling mark for review on question ${currentQuestion + 1}`); markedForReview[currentQuestion] = !markedForReview[currentQuestion]; document.getElementById('mark-review').classList.toggle('marked', markedForReview[currentQuestion]); updateNavPanel(); saveProgress(); debugLog(`Mark for review toggled for question ${currentQuestion + 1}`); } catch (e) { console.error("Error marking for review:", e); debugLog("Failed to mark for review: " + e.message); } } // Navigate to previous question function showPreviousQuestion() { try { debugLog(`Navigating to previous question from ${currentQuestion + 1}`); if (currentQuestion > 0) { currentQuestion--; showQuestion(currentQuestion); } } catch (e) { console.error("Error navigating to previous question:", e); debugLog("Failed to navigate to previous question: " + e.message); } } // Navigate to next question function showNextQuestion() { try { debugLog(`Navigating to next question from ${currentQuestion + 1}`); if (currentQuestion < questions.length - 1) { currentQuestion++; showQuestion(currentQuestion); } } catch (e) { console.error("Error navigating to next question:", e); debugLog("Failed to navigate to next question: " + e.message); } } // Handle question navigation click function handleQuestionNavClick(index) { try { debugLog(`Navigating to question ${index + 1} via nav panel`); showQuestion(index); toggleNavPanel(); } catch (e) { console.error("Error handling navigation click:", e); debugLog("Failed to navigate via nav panel: " + e.message); } } // Start timer function startTimer() { try { debugLog("Starting timer"); timerInterval = setInterval(() => { if (timeRemaining <= 0) { debugLog("Timer expired, submitting test"); clearInterval(timerInterval); submitTest(); } else { timeRemaining--; const minutes = Math.floor(timeRemaining / 60); const seconds = timeRemaining % 60; document.getElementById('timer').innerHTML = `Time Remaining: <span>${minutes.toString().padStart(2, '0')}:${seconds.toString().padStart(2, '0')}</span>`; saveProgress(); } }, 1000); debugLog("Timer started successfully"); } catch (e) { console.error("Error starting timer:", e); debugLog("Failed to start timer: " + e.message); } } // Update progress bar function updateProgressBar() { try { debugLog("Updating progress bar"); const progress = ((currentQuestion + 1) / questions.length) * 100; document.getElementById('progress-bar').style.width = `${progress}%`; debugLog("Progress bar updated"); } catch (e) { console.error("Error updating progress bar:", e); debugLog("Failed to update progress bar: " + e.message); } } // Update quiz navigation panel function updateNavPanel() { try { debugLog("Updating quiz navigation panel"); const filter = document.getElementById('nav-filter').value; const navGrid = document.getElementById('nav-grid'); navGrid.innerHTML = questions.map((_, i) => { if (filter === 'answered' && !answers[i]) return ''; if (filter === 'unanswered' && answers[i]) return ''; if (filter === 'marked' && !markedForReview[i]) return ''; return ` <button class="question-nav-btn ${answers[i] ? 'answered' : 'unanswered'} ${markedForReview[i] ? 'marked-nav' : ''}" onclick="handleQuestionNavClick(${i})" aria-label="Go to Question ${i + 1}"> ${i + 1} </button> `; }).join(''); debugLog("Quiz navigation panel updated"); } catch (e) { console.error("Error updating quiz navigation panel:", e); debugLog("Failed to update quiz navigation panel: " + e.message); } } // Update results navigation panel function updateResultsNavPanel() { try { debugLog("Updating results navigation panel"); const filter = document.getElementById('results-nav-filter').value; const navGrid = document.getElementById('results-nav-grid'); navGrid.innerHTML = questions.map((_, i) => { if (filter === 'answered' && !answers[i]) return ''; if (filter === 'unanswered' && answers[i]) return ''; if (filter === 'marked' && !markedForReview[i]) return ''; return ` <button class="result-nav-btn-grid ${answers[i] ? 'answered' : 'unanswered'} ${markedForReview[i] ? 'marked-nav' : ''}" onclick="handleResultNavClick(${i})" aria-label="Go to Result for Question ${i + 1}"> ${i + 1} </button> `; }).join(''); debugLog("Results navigation panel updated"); } catch (e) { console.error("Error updating results navigation panel:", e); debugLog("Failed to update results navigation panel: " + e.message); } } // Toggle quiz navigation panel function toggleNavPanel() { try { debugLog("Toggling quiz navigation panel"); const navPanel = document.getElementById('nav-panel'); navPanel.classList.toggle('hidden'); debugLog("Quiz navigation panel toggled"); } catch (e) { console.error("Error toggling quiz navigation panel:", e); debugLog("Failed to toggle quiz navigation panel: " + e.message); } } // Toggle results navigation panel function toggleResultsNavPanel() { try { debugLog("Toggling results navigation panel"); const resultsNavPanel = document.getElementById('results-nav-panel'); resultsNavPanel.classList.toggle('hidden'); if (!resultsNavPanel.classList.contains('hidden')) { updateResultsNavPanel(); } debugLog("Results navigation panel toggled"); } catch (e) { console.error("Error toggling results navigation panel:", e); debugLog("Failed to toggle results navigation panel: " + e.message); } } // Handle result navigation click function handleResultNavClick(index) { try { debugLog(`Navigating to result for question ${index + 1} via nav panel`); showResults(index); toggleResultsNavPanel(); } catch (e) { console.error("Error handling result navigation click:", e); debugLog("Failed to navigate to result: " + e.message); } } // Show submit modal function showSubmitModal() { try { debugLog("Showing submit modal"); const attempted = answers.filter(a => a !== null).length; document.getElementById('attempted-count').textContent = attempted; document.getElementById('unattempted-count').textContent = questions.length - attempted; document.getElementById('submit-modal').classList.remove('hidden'); debugLog("Submit modal displayed"); } catch (e) { console.error("Error showing submit modal:", e); debugLog("Failed to show submit modal: " + e.message); } } // Close submit modal function closeSubmitModal() { try { debugLog("Closing submit modal"); document.getElementById('submit-modal').classList.add('hidden'); debugLog("Submit modal closed"); } catch (e) { console.error("Error closing submit modal:", e); debugLog("Failed to close submit modal: " + e.message); } } // Close exit modal function closeExitModal() { try { debugLog("Closing exit modal"); document.getElementById('exit-modal').classList.add('hidden'); debugLog("Exit modal closed"); } catch (e) { console.error("Error closing exit modal:", e); debugLog("Failed to close exit modal: " + e.message); } } // Submit test function submitTest() { try { debugLog("Submitting test"); clearInterval(timerInterval); document.getElementById('quiz').classList.add('hidden'); document.getElementById('submit-modal').classList.add('hidden'); document.getElementById('results').classList.remove('hidden'); showResults(0); // Start with first question // Trigger confetti animation confetti({ particleCount: 100, spread: 70, origin: { y: 0.6 } }); localStorage.removeItem(`quiz_${quizId}`); debugLog("Test submitted successfully"); } catch (e) { console.error("Error submitting test:", e); debugLog("Failed to submit test: " + e.message); } } // Show result for a single question function showResults(index) { try { debugLog(`Showing result for question ${index + 1}`); currentResultQuestion = index; let correct = 0, wrong = 0, unanswered = 0, marked = 0; answers.forEach((answer, i) => { const isCorrect = answer && questions[i].options.find(opt => opt.label === answer)?.correct; if (answer === null) unanswered++; else if (isCorrect) correct++; else wrong++; if (markedForReview[i]) marked++; }); const q = questions[index]; if (!q) { throw new Error(`Question ${index} is undefined`); } const userAnswer = answers[index]; const isCorrect = userAnswer && q.options.find(opt => opt.label === userAnswer)?.correct; const resultsContent = document.getElementById('results-content'); resultsContent.innerHTML = ` <div class="border p-4 rounded-lg ${isCorrect ? 'bg-green-50' : userAnswer ? 'bg-red-50' : 'bg-gray-50'}"> <p class="font-semibold">Question ${index + 1}: ${q.text || 'No question text'}</p> ${q.question_images && q.question_images.length > 0 ? q.question_images.map(url => `<img src="${url}" alt="Question Image" class="max-w-full h-auto rounded-lg my-2">`).join('') : ''} <p><strong>Your Answer:</strong> ${userAnswer ? `${userAnswer}. ${q.options.find(opt => opt.label === userAnswer)?.text || 'Invalid option'}` : 'Unanswered'}</p> <p><strong>Correct Answer:</strong> ${q.correct_answer || 'Unknown'}</p> <div class="mt-2">${q.explanation || 'No explanation available'}</div> ${q.explanation_images && q.explanation_images.length > 0 ? q.explanation_images.map(url => `<img src="${url}" alt="Explanation Image" class="max-w-full h-auto rounded-lg my-2">`).join('') : ''} ${q.video ? ` <button class="play-video bg-blue-500 text-white px-4 py-2 rounded-lg mt-2" onclick="loadVideo(this, '${q.video}', 'video-${index}')" aria-label="Play explanation video for Question ${index + 1}"> Play Video Explanation </button> <div id="video-${index}" class="video-container mt-2"></div> ` : '<p class="text-gray-500 mt-2">No video available</p>'} ${q.audio ? ` <button class="play-audio bg-blue-500 text-white px-4 py-2 rounded-lg mt-2" onclick="loadAudio(this, '${q.audio}', 'audio-${index}')" aria-label="Play audio explanation for Question ${index + 1}"> Play Audio Explanation </button> <div id="audio-${index}" class="audio-container mt-2"></div> ` : ''} </div> `; document.getElementById('correct-count').textContent = correct; document.getElementById('wrong-count').textContent = wrong; document.getElementById('unanswered-count').textContent = unanswered; document.getElementById('marked-count').textContent = marked; document.getElementById('result-question-number').innerHTML = `Question <span>${index + 1}</span> of ${questions.length}`; document.getElementById('prev-result').disabled = index === 0; document.getElementById('next-result').disabled = index === questions.length - 1; updateResultsNavPanel(); window.scrollTo({ top: 0, behavior: 'smooth' }); debugLog(`Result for question ${index + 1} displayed successfully`); } catch (e) { console.error("Error displaying result:", e); debugLog("Failed to display result: " + e.message); } } // Navigate to previous result function showPreviousResult() { try { debugLog(`Navigating to previous result from question ${currentResultQuestion + 1}`); if (currentResultQuestion > 0) { showResults(currentResultQuestion - 1); } } catch (e) { console.error("Error navigating to previous result:", e); debugLog("Failed to navigate to previous result: " + e.message); } } // Navigate to next result function showNextResult() { try { debugLog(`Navigating to next result from question ${currentResultQuestion + 1}`); if (currentResultQuestion < questions.length - 1) { showResults(currentResultQuestion + 1); } } catch (e) { console.error("Error navigating to next result:", e); debugLog("Failed to navigate to next result: " + e.message); } } // Lazy-load video function loadVideo(button, videoUrl, containerId) { try { debugLog(`Loading video for ${containerId}: ${videoUrl}`); if (!videoUrl) { const container = document.getElementById(containerId); container.innerHTML = `<p class="text-gray-500">No video available</p>`; button.remove(); debugLog("No video URL provided"); return; } const container = document.getElementById(containerId); container.innerHTML = ` <div class="video-loading"></div> <video controls class="w-full max-w-[600px] rounded-lg" preload="metadata" aria-label="Video explanation"> <source src="${videoUrl}" type="${videoUrl.endsWith('.m3u8') ? 'application/x-mpegURL' : 'video/mp4'}"> Your browser does not support the video tag. </video> `; container.classList.add('active'); button.remove(); // Initialize HLS.js for .m3u8 videos const video = container.querySelector('video'); if (videoUrl.endsWith('.m3u8') && Hls.isSupported()) { const hls = new Hls(); hls.loadSource(videoUrl); hls.attachMedia(video); hls.on(Hls.Events.ERROR, (event, data) => { console.error("HLS.js error:", data); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; debugLog("HLS.js error: " + JSON.stringify(data)); }); } else if (videoUrl.endsWith('.m3u8') && video.canPlayType('application/vnd.apple.mpegurl')) { video.src = videoUrl; } // Handle video load errors video.onerror = () => { console.error("Video load error for URL:", videoUrl); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; debugLog("Video load error for URL: " + videoUrl); }; // Remove loading spinner when video is ready video.onloadedmetadata = () => { container.querySelector('.video-loading').remove(); debugLog("Video loaded successfully"); }; } catch (e) { console.error("Error loading video:", e); debugLog("Failed to load video: " + e.message); const container = document.getElementById(containerId); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; } } // Lazy-load audio function loadAudio(button, audioUrl, containerId) { try { debugLog(`Loading audio for ${containerId}: ${audioUrl}`); if (!audioUrl) { const container = document.getElementById(containerId); container.innerHTML = `<p class="text-gray-500">No audio available</p>`; button.remove(); debugLog("No audio URL provided"); return; } const container = document.getElementById(containerId); container.innerHTML = ` <audio controls class="w-full max-w-[600px]" preload="metadata" aria-label="Audio explanation"> <source src="${audioUrl}" type="audio/mpeg"> Your browser does not support the audio tag. </audio> `; container.classList.add('active'); button.remove(); // Handle audio load errors const audio = container.querySelector('audio'); audio.onerror = () => { console.error("Audio load error for URL:", audioUrl); container.innerHTML = `<p class="text-red-500">Error loading audio. <a href="${audioUrl}" target="_blank" aria-label="Open audio in new tab">Open audio</a></p>`; debugLog("Audio load error for URL: " + audioUrl); }; debugLog("Audio loaded successfully"); } catch (e) { console.error("Error loading audio:", e); debugLog("Failed to load audio: " + e.message); const container = document.getElementById(containerId); container.innerHTML = `<p class="text-red-500">Error loading audio. <a href="${audioUrl}" target="_blank" aria-label="Open audio in new tab">Open audio</a></p>`; } } // Toggle dark mode function toggleTheme() { try { debugLog("Toggling theme"); document.documentElement.classList.toggle('dark'); localStorage.setItem('theme', document.documentElement.classList.contains('dark') ? 'dark' : 'light'); debugLog("Theme toggled successfully"); } catch (e) { console.error("Error toggling theme:", e); debugLog("Failed to toggle theme: " + e.message); } } // Load theme preference function loadTheme() { try { debugLog("Loading theme preference"); const theme = localStorage.getItem('theme'); if (theme === 'dark') { document.documentElement.classList.add('dark'); } debugLog("Theme loaded successfully"); } catch (e) { console.error("Error loading theme:", e); debugLog("Failed to load theme: " + e.message); } } // Initialize on DOM content loaded window.addEventListener('DOMContentLoaded', () => { try { debugLog("DOM content loaded, initializing quiz"); loadTheme(); initQuiz(); } catch (e) { console.error("Error during DOMContentLoaded:", e); debugLog("Failed to initialize on DOMContentLoaded: " + e.message); document.getElementById('error-message').innerHTML = "Error initializing quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); } }); </script> </body> </html>" frameborder="0" width="100%" height="2000px">
<div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <h2 class="text-xl font-semibold mb-4">Instructions</h2> <h4 class="text-gray-800 text-lg font-semibold mt-6 mb-4">Test Features:</h4> <ul class="space-y-3"> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Multiple choice questions with single correct answers </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Timer-based testing for realistic exam conditions </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Mark questions for review functionality </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Comprehensive results and performance analysis </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Mobile-optimized interface for learning on-the-go </li> </ul> <div class="mt-6 flex space-x-4 button-group md:flex-row flex-col"> <button class="bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="start-test">Start Test</button> </div> <div class="error-message hidden" id="error-message"></div> </div> </section> <!-- Quiz Section --> <section class="container mx-auto px-4 md:px-6 pt-4 md:pt-6 pb-1 hidden section-transition" id="quiz"> <div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <!-- Progress Bar --> <div class="w-full bg-gray-200 rounded-full h-3 mb-4"> <div class="progress-bar h-3 rounded-full" id="progress-bar" style="width: 0%"></div> </div> <!-- Question Header --> <div class="flex flex-col md:flex-row justify-between items-center mb-4"> <h2 class="text-lg font-semibold" id="question-number">Question <span>1</span> of 4</h2> <p class="text-lg font-semibold mt-2 md:mt-0" id="timer">Time Remaining: <span>00:00</span></p> </div> <!-- Question Content --> <div class="mb-6" id="question-content"> <p class="text-gray-800 mb-4" id="question-text"></p> <div class="flex flex-wrap gap-4 mb-4" id="question-images"></div> <div class="space-y-3" id="options"></div> </div> <!-- Navigation Buttons --> <div class="flex flex-col md:flex-row justify-between items-center gap-2 md:gap-4"> <div class="flex gap-2 w-full md:w-auto"> <button class="bg-[#2c5281] text-white px-4 py-3 w-full md:w-32 h-14 rounded-lg hover:bg-[#2c5281] transition" disabled="" id="previous-btn">Previous</button> <button class="bg-[#2c5281] text-white px-4 py-3 w-full md:w-32 h-14 rounded-lg hover:bg-[#2c5281] transition" id="next-btn">Next</button> </div> <div class="flex items-center gap-2"> <button class="bg-transparent text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-100 transition flex items-center gap-1" id="mark-review"> Review <svg xmlns="http://www.w3.org/2000/svg" class="h-5 w-5" viewBox="0 0 20 20" fill="currentColor"> <path d="M10 2a1 1 0 00-1 1v14l3.293-3.293a1 1 0 011.414 0L17 17V3a1 1 0 00-1-1H10z" /> </svg> </button> <button class="bg-transparent text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-100 transition flex items-center gap-1" id="nav-toggle"> Question 🧭 </button> <button class="bg-green-500 text-white px-6 py-3 w-44 h-14 rounded-lg hover:bg-green-600 transition w-full md:w-auto" id="submit-test">Submit Test</button> </div> </div> </section> <!-- Results Section --> <section class="container mx-auto px-4 md:px-6 pt-4 md:pt-6 pb-1 hidden section-transition" id="results"> <div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <h2 class="text-2xl font-semibold mb-4">Anaesthesia Machine - Results</h2> <div class="grid grid-cols-1 md:grid-cols-2 gap-4 mb-6"> <p><strong>Correct:</strong> <span id="correct-count" class="text-[#000000]">0</span></p> <p><strong>Wrong:</strong> <span id="wrong-count" class="text-[#000000]">0</span></p> <p><strong>Unanswered:</strong> <span id="unanswered-count" class="text-[#000000]-500">0</span></p> <p><strong>Marked for Review:</strong> <span id="marked-count" class="text-[#000000]">0</span></p> </div> <h3 class="text-lg font-semibold mb-4" id="result-question-number">Question <span>1</span> of 4</h3> <div class="space-y-6" id="results-content"></div> <div class="result-nav"> <button aria-label="Previous question result" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" disabled="" id="prev-result">Previous</button> <button aria-label="Toggle results navigation panel" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="results-nav-toggle">Result 🧭</button> <button aria-label="Next question result" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="next-result">Next</button> </div> <div class="mt-6 flex space-x-4 button-group md:flex-row flex-col"> <button class="bg-green-500 text-white px-6 py-2 rounded-lg hover:bg-green-600 transition" id="take-again">Take Again</button> </div> </div> </section> <!-- Exit Confirmation Modal --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 hidden" id="exit-modal" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white rounded-lg p-6 max-w-sm w-full"> <h2 class="text-xl font-semibold mb-4">Leave Test?</h2> <p class="text-gray-700 mb-4">Your progress will be lost if you leave this page. Are you sure you want to exit?</p> <div class="flex justify-end space-x-4"> <button class="bg-gray-300 text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-400 transition" id="continue-test">No, Continue</button> <button class="bg-red-500 text-white px-4 py-2 rounded-lg hover:bg-red-600 transition" id="exit-test">Yes, Exit</button> </div> </div> </div> <!-- Submit Confirmation Modal --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 hidden" id="submit-modal" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white rounded-lg p-6 max-w-sm w-full"> <h2 class="text-xl font-semibold mb-4">Confirm Submission</h2> <p class="text-gray-700 mb-2">You have attempted <span id="attempted-count">0</span> of 4 questions.</p> <p class="text-gray-700 mb-4"><span id="unattempted-count">0</span> questions are unattempted.</p> <div class="flex justify-end space-x-4"> <button class="bg-gray-300 text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-400 transition" id="cancel-submit">Cancel</button> <button class="text-white px-4 py-2 rounded-lg hover:bg-[#1a365d] transition" style="background-color: #2c5281;" id="confirm-submit">Submit Test</button> </div> </div> </div> <!-- Quiz Navigation Panel --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 z-50 nav-panel hidden overflow-y-auto" id="nav-panel" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white shadow-lg p-4 rounded-lg w-full max-w-2xl max-h-[80vh] overflow-y-auto"> <h2 class="text-lg font-semibold mb-4">Questions Navigation</h2> <div class="mb-4"> <select class="w-full p-2 border rounded-lg text-gray-700" id="nav-filter"> <option value="all">All Questions</option> <option value="answered">Answered</option> <option value="unanswered">Unanswered</option> <option value="marked">Marked for Review</option> </select> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-nav">Close</button> </div> </div> <!-- Results Navigation Panel --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 z-50 results-nav-panel hidden overflow-y-auto" id="results-nav-panel" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white shadow-lg p-4 rounded-lg w-full max-w-2xl max-h-[80vh] overflow-y-auto"> <h2 class="text-lg font-semibold mb-4">Results Navigation</h2> <div class="mb-4"> <select class="w-full p-2 border rounded-lg text-gray-700" id="results-nav-filter"> <option value="all">All Questions</option> <option value="answered">Answered</option> <option value="unanswered">Unanswered</option> <option value="marked">Marked for Review</option> </select> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="results-nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-results-nav">Close</button> </div> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="results-nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-results-nav">Close</button> </div> <!-- JavaScript Logic --> <script> // Enable debug mode for detailed logging const DEBUG_MODE = true; // Log debug messages function debugLog(message) { if (DEBUG_MODE) { console.log(`[DEBUG] ${message}`); } } // Initialize questions with error handling let questions = []; let currentResultQuestion = 0; // State for current question in results try { debugLog("Attempting to parse questions_json"); questions = [{"text": "A 50-year-old, chronic alcoholic male with history of high-grade fever with chills expired at home. His postmortem examination showed the following finding on liver sections. What is the most common cause of the below condition?", "options": [{"label": "A", "text": "Portal pyemia", "correct": false}, {"label": "B", "text": "Empyema of Gall Bladder", "correct": false}, {"label": "C", "text": "Ascending cholangitis", "correct": true}, {"label": "D", "text": "Entameba", "correct": false}], "correct_answer": "C. Ascending cholangitis", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture17.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C. Ascending cholangitis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Portal Pyemia. Portal pyemia refers to infection in the portal vein system , which can result in multiple liver abscesses due to the spread of bacteria from the gastrointestinal tract . However, it is not the most common cause of pyogenic liver abscesses.</li><li>• Option A: Portal Pyemia.</li><li>• infection in the portal vein system</li><li>• multiple liver abscesses due to the spread of bacteria from the gastrointestinal tract</li><li>• Option B: Empyema of Gall Bladder. Empyema of the gallbladder is the accumulation of pus within the gallbladder , which can lead to liver abscesses if the infection spreads , but it is not as common as biliary tract infections leading to cholangitis.</li><li>• Option B: Empyema of Gall Bladder.</li><li>• accumulation of pus within the gallbladder</li><li>• liver abscesses if the infection spreads</li><li>• Option D: Entameba. Entameba can lead to amebic liver abscess . However, the given condition of high grade fever with chills, and yellow colored purulent lesions are not seen. Amebic liver abscess shows anchovy sauce pus.</li><li>• Option D: Entameba.</li><li>• lead to amebic liver abscess</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Ascending cholangitis , due to infection ascending the biliary tree , is a common cause of pyogenic liver abscesses and is typically associated with polymicrobial infections involving organisms such as Klebsiella, E. coli, and Streptococcus milleri group . Diagnosis and management involve imaging, aspiration, and appropriate antibiotic therapy.</li><li>➤ Ascending cholangitis</li><li>➤ infection ascending the biliary tree</li><li>➤ common cause of pyogenic liver abscesses</li><li>➤ polymicrobial infections involving organisms such as Klebsiella, E. coli, and Streptococcus milleri group</li><li>➤ Biliary tract pathology is the most common source (35%), followed by portal spread from the gastrointestinal tract, including diverticulitis and appendicitis (20%). Other unusual etiologies include contiguous spread from sub phrenic or intra-abdominal collections, bacteremia secondary to trauma or infected cysts and necrotic tumors following chemotherapy. Worldwide, bacteria remain the most common; although infection is usually polymicrobial Klebsiella, Escherichia coli and the Streptococcus milleri group are the usual organisms identified. There is an increased incidence in the elderly, those with diabetes and the immunosuppressed and presentation is usually with anorexia, fever, and malaise and right upper quadrant discomfort The diagnosis is suggested by the finding of a multiloculated cystic mass on ultrasonography or CT scan and is confirmed by aspiration. Treatment of liver abscesses initially requires identification of the source, if possible, aspiration of the lesion for microbiology and culture (repeated aspirations may be required) and treatment with appropriate antibiotics A combination of two or more antibiotics is recommended. Metronidazole and clindamycin provide wide anaerobic coverage and excellent penetration into the abscess cavity. Third-generation cephalosporins and aminoglycosides are very effective against most Gram-negative organisms.</li><li>➤ Biliary tract pathology is the most common source (35%), followed by portal spread from the gastrointestinal tract, including diverticulitis and appendicitis (20%).</li><li>➤ Other unusual etiologies include contiguous spread from sub phrenic or intra-abdominal collections, bacteremia secondary to trauma or infected cysts and necrotic tumors following chemotherapy.</li><li>➤ Worldwide, bacteria remain the most common; although infection is usually polymicrobial Klebsiella, Escherichia coli and the Streptococcus milleri group are the usual organisms identified.</li><li>➤ There is an increased incidence in the elderly, those with diabetes and the immunosuppressed and presentation is usually with anorexia, fever, and malaise and right upper quadrant discomfort</li><li>➤ The diagnosis is suggested by the finding of a multiloculated cystic mass on ultrasonography or CT scan and is confirmed by aspiration.</li><li>➤ Treatment of liver abscesses initially requires identification of the source, if possible, aspiration of the lesion for microbiology and culture (repeated aspirations may be required) and treatment with appropriate antibiotics</li><li>➤ A combination of two or more antibiotics is recommended. Metronidazole and clindamycin provide wide anaerobic coverage and excellent penetration into the abscess cavity. Third-generation cephalosporins and aminoglycosides are very effective against most Gram-negative organisms.</li><li>➤ Ref: Bailey 28 th Ed. Pg 1209</li><li>➤ Ref: Bailey 28 th Ed. Pg 1209</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A female patient with a BMI of 30kg/m 2 came to the OPD with complaints of right upper quadrant pain since 7 days. She has history of consumption of OCPs. The following imaging was obtained. What is the incorrect statement with respect to the below condition?", "options": [{"label": "A", "text": "Pigment stones can form due to biliary tract infections", "correct": false}, {"label": "B", "text": "The most common type of bile stones in Asia are cholesterol stones", "correct": true}, {"label": "C", "text": "Mirizzi syndrome is a condition where gall stones are associated with jaundice", "correct": false}, {"label": "D", "text": "Untreated cholecystitis may lead to mucocele of the gall bladder", "correct": false}], "correct_answer": "B. The most common type of bile stones in Asia are cholesterol stones", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture21.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B) The most common type of bile stones in Asia are cholesterol stones.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Pigment Stones Can Form Due to Biliary Tract Infections. This statement is correct . Brown pigment stones are often associated with chronic biliary tract infections, parasitic infections, or bile stasis.</li><li>• Option A: Pigment Stones Can Form Due to Biliary Tract Infections.</li><li>• correct</li><li>• Option C: Mirizzi Syndrome is Associated with Jaundice. Mirizzi syndrome is a rare complication of gallstones where a gallstone becomes impacted in the cystic duct or neck of the gallbladder and can compress the common hepatic duct leading to jaundice. This statement is correct.</li><li>• Option C: Mirizzi Syndrome is Associated with Jaundice.</li><li>• correct.</li><li>• Option D: Untreated Cholecystitis May Lead to Mucocele of the Gall Bladder. This statement is correct . If the cystic duct is obstructed, the gallbladder can fill with mucus or clear fluid, leading to a mucocele, which is a gallbladder that is distended with mucus and not bile.</li><li>• Option D: Untreated Cholecystitis May Lead to Mucocele of the Gall Bladder.</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In Asia , the most common type of gallstones are pigment stones , often related to biliary tract infections or hemolytic conditions . Mirizzi syndrome involves the obstruction of the common hepatic duct by a gallstone , leading to jaundice , and untreated cholecystitis can progress to mucocele of the gallbladder.</li><li>➤ Asia</li><li>➤ most common type of gallstones are pigment stones</li><li>➤ biliary tract infections or hemolytic conditions</li><li>➤ Mirizzi syndrome</li><li>➤ obstruction of the common hepatic duct by a gallstone</li><li>➤ jaundice</li><li>➤ Types of gallstones</li><li>➤ Types of gallstones</li><li>➤ Cholesterol stones / mixed type MC type in western world - radiolucent Pigment stones -MC type in Asia - two types. Brown pigment stone: due to worms/foreign body in CBD; radio opaque Black pigment stones: due hemolytic anemia, also radio opaque</li><li>➤ Cholesterol stones / mixed type MC type in western world - radiolucent</li><li>➤ MC type in western world - radiolucent</li><li>➤ MC type in western world - radiolucent</li><li>➤ Pigment stones -MC type in Asia - two types. Brown pigment stone: due to worms/foreign body in CBD; radio opaque Black pigment stones: due hemolytic anemia, also radio opaque</li><li>➤ Brown pigment stone: due to worms/foreign body in CBD; radio opaque Black pigment stones: due hemolytic anemia, also radio opaque</li><li>➤ Brown pigment stone: due to worms/foreign body in CBD; radio opaque</li><li>➤ Black pigment stones: due hemolytic anemia, also radio opaque</li><li>➤ Ref: Bailey 28 th Ed. Page 1244</li><li>➤ Ref: Bailey 28 th Ed. Page 1244</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 58-year-old male with history of chronic alcohol consumption on routine check-up was found to have hepatomegaly. His LFT was essentially normal, Serum AFP was 490 ng//ml. CECT showed rapidly enhancing mass in the setting of nodularity. What is the likely diagnosis?", "options": [{"label": "A", "text": "Hepatic adenoma", "correct": false}, {"label": "B", "text": "Hemangioma", "correct": false}, {"label": "C", "text": "Metastasis", "correct": false}, {"label": "D", "text": "Hepatoma", "correct": true}], "correct_answer": "D. Hepatoma", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D. Hepatoma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Hepatic Adenoma. Hepatic adenoma is a benign liver tumor often associated with oral contraceptive use and anabolic steroid use , less commonly linked to alcohol. They typically do not show rapid enhancement and washout on imaging, making this less likely in the context of cirrhosis and elevated AFP.</li><li>• Option A: Hepatic Adenoma.</li><li>• benign liver tumor</li><li>• associated with oral contraceptive use and anabolic steroid use</li><li>• Option B: Hemangioma. Liver hemangiomas are the most common benign liver tumors and are typically asymptomatic. On imaging, they show a characteristic pattern of peripheral nodular enhancement with centripetal filling, not early arterial enhancement and venous washout.</li><li>• Option B: Hemangioma.</li><li>• most common benign liver tumors and are typically asymptomatic.</li><li>• Option C: Metastasis. Metastatic lesions to the liver can present with various imaging features , but the combination of cirrhosis , elevated AFP , and the described enhancement pattern is more suggestive of primary liver cancer than metastasis.</li><li>• Option C: Metastasis.</li><li>• liver can present with various imaging features</li><li>• combination of cirrhosis</li><li>• elevated AFP</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In a patient with cirrhosis and an elevated AFP who presents with a liver mass showing early arterial enhancement and venous phase washout on imaging , hepatocellular carcinoma (HCC) is the most likely diagnosis.</li><li>➤ cirrhosis and an elevated AFP</li><li>➤ liver mass showing early arterial enhancement</li><li>➤ venous phase washout on imaging</li><li>➤ hepatocellular carcinoma</li><li>➤ Chronic hepatitis B virus (HBV) infection accounts for &gt;50% of cases worldwide and HBV vaccination programmes reduce the incidence in high-risk areas. Hepatitis C virus (HCV) increases the risk of HCC 17-fold by promoting end-stage liver disease. Lifetime alcohol exposure remains an intractable risk factor and correlates with the incidence of HCC. Obesity and diabetes mellitus are additional independent risk factors Imaging is a critical part of the preoperative assessment of HCC and accurate tumour staging and anatomical assessment is essential to determine technical and oncological resectability and exclude metastatic disease. Triple-phase CT chest/ abdomen/pelvis and MRI of the liver is the standard of care, The early arterial phase following intravenous contrast detects small hepatocellular carcinomas (HCCs) owing to their predominantly arterial blood supply. The venous phase demonstrates branches of the intrahepatic portal vein and the hepatic veins. Inflammatory liver lesions often exhibit rim enhancement with intravenous contrast, whereas haemangiomas characteristically show late venous enhancement.</li><li>➤ Chronic hepatitis B virus (HBV) infection accounts for &gt;50% of cases worldwide and HBV vaccination programmes reduce the incidence in high-risk areas.</li><li>➤ Hepatitis C virus (HCV) increases the risk of HCC 17-fold by promoting end-stage liver disease.</li><li>➤ Lifetime alcohol exposure remains an intractable risk factor and correlates with the incidence of HCC.</li><li>➤ Obesity and diabetes mellitus are additional independent risk factors</li><li>➤ Imaging is a critical part of the preoperative assessment of HCC and accurate tumour staging and anatomical assessment is essential to determine technical and oncological resectability and exclude metastatic disease.</li><li>➤ Triple-phase CT chest/ abdomen/pelvis and MRI of the liver is the standard of care,</li><li>➤ The early arterial phase following intravenous contrast detects small hepatocellular carcinomas (HCCs) owing to their predominantly arterial blood supply. The venous phase demonstrates branches of the intrahepatic portal vein and the hepatic veins.</li><li>➤ Inflammatory liver lesions often exhibit rim enhancement with intravenous contrast, whereas haemangiomas characteristically show late venous enhancement.</li><li>➤ Ref: Bailey 28 th Ed. Pg 1196, 1215</li><li>➤ Ref: Bailey 28 th Ed. Pg 1196, 1215</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "According to the Strassberg classification, injury to the right posterior sectoral duct with leakage is which type of acute bile duct injury?", "options": [{"label": "A", "text": "A", "correct": false}, {"label": "B", "text": "B", "correct": false}, {"label": "C", "text": "C", "correct": true}, {"label": "D", "text": "D", "correct": false}], "correct_answer": "C. C", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture27.jpg"], "explanation": "<p><strong>Ans. C) C</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Types - Strassberg classification of bile duct injury</li><li>• Types - Strassberg classification of bile duct injury</li><li>• Types - Strassberg classification of bile duct injury</li><li>• A -cystic duct leak</li><li>• B - Right posterior duct injured by ligation - no leak</li><li>• C – Right posterior duct cut and leaks - bile leak into peritoneal cavity</li><li>• C – Right posterior duct cut and leaks - bile leak into peritoneal cavity</li><li>• D - Injury to CHD lateral wall - major leak - major peritonitis</li><li>• E - Stricture</li><li>• Bismuth classification of biliary stricture</li><li>• Bismuth classification of biliary stricture</li><li>• Bismuth classification of biliary stricture</li><li>• E1 - low stricture, away from confluence (&gt; 2 cm away)</li><li>• E2 - near confluence (within 2 cm)</li><li>• E3 - at confluence</li><li>• E4 - involving right and left ducts</li><li>• E5 - stricture of right posterior duct (late complication of Strassberg B, common bile duct doesn’t get injured in this) and main duct</li><li>• Ref: Bailey 28 th Ed. Pg 1252</li><li>• Ref:</li><li>• Bailey 28 th Ed. Pg 1252</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is the most common functioning pancreatic endocrine neoplasm?", "options": [{"label": "A", "text": "Glucagonoma", "correct": false}, {"label": "B", "text": "Insulinoma", "correct": true}, {"label": "C", "text": "Gastrinoma", "correct": false}, {"label": "D", "text": "VIPoma", "correct": false}], "correct_answer": "B. Insulinoma", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Insulinoma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Glucagonoma. Glucagonomas are rare pancreatic endocrine tumors that secrete glucagon , leading to symptoms such as mild diabetes , a characteristic rash known as necrolytic migratory erythema, weight loss, and anemia .</li><li>• Option A: Glucagonoma.</li><li>• rare pancreatic endocrine tumors</li><li>• secrete glucagon</li><li>• mild diabetes</li><li>• necrolytic migratory erythema, weight loss, and anemia</li><li>• Option C: Gastrinoma. Gastrinomas are the second most common functioning PNET and the most common functional pancreatic tumor in multiple endocrine neoplasia type 1 (MEN 1) syndrome. They secrete gastrin, causing peptic ulcers and diarrhea (Zollinger-Ellison syndrome).</li><li>• Option C: Gastrinoma.</li><li>• second most common</li><li>• PNET and the most common functional pancreatic tumor</li><li>• multiple endocrine neoplasia type 1</li><li>• Option D: VIPoma. VIPomas are rare pancreatic tumors that secrete vasoactive intestinal peptide (VIP), leading to watery diarrhea, hypokalemia, and achlorhydria (WDHA syndrome).</li><li>• Option D: VIPoma.</li><li>• rare pancreatic tumors</li><li>• secrete vasoactive intestinal peptide</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Insulinoma is the most common functioning pancreatic endocrine neoplasm , typically presenting with Whipple's triad , which includes symptoms of hypoglycaemia induced by fasting , confirmed hypoglycaemia when symptoms occur, and relief of symptoms with glucose administration.</li><li>➤ Insulinoma</li><li>➤ most common functioning pancreatic endocrine neoplasm</li><li>➤ Whipple's triad</li><li>➤ symptoms of hypoglycaemia induced by fasting</li><li>➤ Insulinomas have been diagnosed in all age groups , with the highest incidence found in the fourth to the sixth decades . Women seem to be slightly more frequently affected.</li><li>➤ Insulinomas</li><li>➤ age groups</li><li>➤ highest incidence</li><li>➤ fourth to the sixth decades</li><li>➤ The cornerstone of diagnosis remains Whipple ’ s triad:</li><li>➤ The cornerstone of diagnosis remains Whipple</li><li>➤ s triad:</li><li>➤ Symptoms induced by fasting. Hypoglycemia at the time of symptoms. Symptoms relieved by administration of glucose.</li><li>➤ Symptoms induced by fasting.</li><li>➤ Symptoms induced by fasting.</li><li>➤ Hypoglycemia at the time of symptoms.</li><li>➤ Hypoglycemia at the time of symptoms.</li><li>➤ Symptoms relieved by administration of glucose.</li><li>➤ Symptoms relieved by administration of glucose.</li><li>➤ Gastrin-secreting PNET (gastrinoma) is the second most common functional pancreatic endocrine tumor but is the MC functional pancreatic tumor in MEN 1 syndrome.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 906</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 906</li><li>➤ Sabiston Textbook of Surgery 20th Edition Page 952</li><li>➤ Sabiston Textbook of Surgery 20th Edition Page 952</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "TIPSS creates a shunt between which 2 veins?", "options": [{"label": "A", "text": "Portal vein and IVC", "correct": false}, {"label": "B", "text": "Portal vein and internal jugular vein", "correct": false}, {"label": "C", "text": "Portal vein and hepatic vein", "correct": true}, {"label": "D", "text": "Portal vein and splenic vein", "correct": false}], "correct_answer": "C. Portal vein and hepatic vein", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture45.jpg"], "explanation": "<p><strong>Ans. C. Portal vein and hepatic vein</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• TIPSS (trans-jugular intrahepatic porto-systemic shunt) has replaced surgical porto-caval shunt and is now accepted as the preferred method for treating refractory portal hypertension</li><li>• TIPSS</li><li>• replaced surgical porto-caval shunt</li><li>• accepted as the preferred method for treating refractory portal hypertension</li><li>• A TIPSS is inserted under local anesthesia , analgesia and sedation using fluoroscopic guidance and ultrasonography. Via the internal jugular vein, superior vena cava and hepatic vein,</li><li>• TIPSS is inserted under local anesthesia</li><li>• analgesia</li><li>• sedation</li><li>• hepatic vein,</li><li>• a guidewire is inserted through the hepatic parenchyma into a branch of portal vein.</li><li>• a guidewire is inserted through the hepatic parenchyma into a branch of portal vein.</li><li>• The tract is dilated ; a metallic stent is then inserted and expanded , forming a portovenous channel . A satisfactory drop in portal venous pressure is usually associated with good control of the variceal hemorrhage.</li><li>• tract is dilated</li><li>• metallic stent is then inserted and expanded</li><li>• portovenous channel</li><li>• The main early complication is perforation of the liver capsule , with potentially fatal intraperitoneal hemorrhage . TIPSS occlusion may produce further variceal hemorrhage and occurs more commonly in patients with well-compensated liver disease and good synthetic function.</li><li>• main early complication is perforation</li><li>• liver capsule</li><li>• potentially fatal intraperitoneal hemorrhage</li><li>• The incidence of post-TIPSS encephalopathy is comparable to that following surgical shunts (40%) and due to portal blood avoiding hepatic detoxification, if severe, flow is reduced by inserting a smaller stent.</li><li>• The incidence of post-TIPSS encephalopathy is comparable to that following surgical shunts (40%) and due to portal blood avoiding hepatic detoxification, if severe, flow is reduced by inserting a smaller stent.</li><li>• The main contraindication to TIPSS is portal vein occlusion, and long-term stenosis occurs in 50% of patients at 1 year.</li><li>• The main contraindication to TIPSS is portal vein occlusion, and long-term stenosis occurs in 50% of patients at 1 year.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ TIPSS establishes a shunt between the portal vein and the hepatic vein to reduce portal hypertension and control complications such as variceal bleeding .</li><li>➤ TIPSS</li><li>➤ shunt between the portal vein and the hepatic vein</li><li>➤ reduce portal hypertension</li><li>➤ variceal bleeding</li><li>➤ Ref : Bailey 28 th Ed. Pg 1205</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 1205</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In a case of acute pancreatitis, biliary pancreatitis was diagnosed as the likely etiology. When would you perform a laparoscopic cholecystectomy in this case?", "options": [{"label": "A", "text": "Not required", "correct": false}, {"label": "B", "text": "After 6 weeks", "correct": false}, {"label": "C", "text": "As soon as patient is fit for surgery, before discharge", "correct": true}, {"label": "D", "text": "After 3 weeks", "correct": false}], "correct_answer": "C. As soon as patient is fit for surgery, before discharge", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) As soon as patient is fit for surgery, before discharge</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Not required. This option is incorrect because in the case of gallstone pancreatitis, removal of the gallbladder is necessary to prevent recurrence of pancreatitis .</li><li>• Option A:</li><li>• Not required.</li><li>• incorrect</li><li>• case of gallstone pancreatitis,</li><li>• removal of the gallbladder</li><li>• recurrence of pancreatitis</li><li>• Option B: After 6 weeks . Traditionally, delayed cholecystectomy was considered to allow inflammation to resolve . However, this is not the preferred approach in the case of biliary pancreatitis where early intervention is advised.</li><li>• Option B: After 6 weeks</li><li>• delayed cholecystectomy</li><li>• allow inflammation to resolve</li><li>• Option D: After 3 weeks . Waiting for a specific time such as 3 weeks is less favored as the risk of recurrent gallstone- related complications remains until the gallbladder is removed.</li><li>• Option D:</li><li>• After 3 weeks</li><li>• Waiting for a specific time</li><li>• 3 weeks is less favored</li><li>• risk of recurrent gallstone-</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Perform laparoscopic cholecystectomy in patients with gallstone pancreatitis as soon as they are stable and fit for surgery to prevent the recurrence of pancreatitis, ideally before discharge from the hospital.</li><li>➤ laparoscopic cholecystectomy</li><li>➤ gallstone pancreatitis</li><li>➤ are stable and fit for surgery to prevent the recurrence of pancreatitis,</li><li>➤ before discharge from the hospital.</li><li>➤ In a patient who has gallstone pancreatitis, the gallbladder and gallstones should be removed as soon as the patient is fit to undergo surgery and, preferably, before discharge from hospital.</li><li>➤ In a patient who has gallstone pancreatitis, the gallbladder and gallstones should be removed as soon as the patient is fit to undergo surgery and, preferably, before discharge from hospital.</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1277</li><li>➤ Ref:</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 1277</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient presented with acute pain in abdomen which radiated to the back and is relieved on sitting bent forwards. The following sign was seen on examination. Which sign is shown?", "options": [{"label": "A", "text": "Grey Turner sign", "correct": false}, {"label": "B", "text": "Cullen sign", "correct": true}, {"label": "C", "text": "Rovsing sign", "correct": false}, {"label": "D", "text": "McBurney sign", "correct": false}], "correct_answer": "B. Cullen sign", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture37.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B) Cullen sign</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Grey Turner sign is the bruising and discoloration of the flanks due to retroperitoneal bleeding, which can occur in conditions like acute pancreatitis.</li><li>• Option A:</li><li>• Grey Turner sign</li><li>• bruising and discoloration of the flanks due to retroperitoneal bleeding,</li><li>• Option C: Rovsing sign is a clinical sign used to diagnose appendicitis . It involves applying pressure to the left lower quadrant of the abdomen , which may cause pain in the right lower quadrant in cases of appendicitis.</li><li>• Option C:</li><li>• Rovsing sign</li><li>• used to diagnose appendicitis</li><li>• applying pressure to the left lower quadrant of the abdomen</li><li>• Option D: McBurney sign is also related to the diagnosis of appendicitis . It indicates the point of maximum tenderness in the right lower quadrant of the abdomen.</li><li>• Option D:</li><li>• McBurney sign</li><li>• diagnosis of appendicitis</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Cullen sign , characterized by peri-umbilical bruising due to retroperitoneal bleeding, is a clinical feature associated with conditions like acute pancreatitis.</li><li>➤ Cullen sign</li><li>➤ peri-umbilical bruising due to retroperitoneal bleeding,</li><li>➤ acute pancreatitis.</li><li>➤ Acute pancreatitis- clinical features :</li><li>➤ Acute pancreatitis- clinical features</li><li>➤ Symptoms -</li><li>➤ Symptoms</li><li>➤ Acute pain in abdomen which radiates to the back and is relieved on sitting bent forwards. nausea, repeated vomiting and retching</li><li>➤ Acute pain in abdomen which radiates to the back and is relieved on sitting bent forwards.</li><li>➤ nausea, repeated vomiting and retching</li><li>➤ Signs -</li><li>➤ Signs</li><li>➤ Tachycardia Tachypnea Hypotension Mild icterus Bluish discolouration of flanks- Grey Turner sign (due to retroperitoneal bleed) Subcutaneous fat necrosis seen as small, red, tender nodules on legs</li><li>➤ Tachycardia</li><li>➤ Tachypnea</li><li>➤ Hypotension</li><li>➤ Mild icterus</li><li>➤ Bluish discolouration of flanks- Grey Turner sign (due to retroperitoneal bleed)</li><li>➤ Subcutaneous fat necrosis seen as small, red, tender nodules on legs</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1271</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1271</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old patient underwent a lap cholecystectomy for gallstones. On day 2 in the postoperative period, he experienced fever and pain in the right hypochondrium. Ultrasonography revealed 200cc of fluid in the GB fossa. What is your next step?", "options": [{"label": "A", "text": "Ultrasound-guided drainage", "correct": true}, {"label": "B", "text": "Endoscopic retrograde cholangiopancreatography (ERCP) and stenting", "correct": false}, {"label": "C", "text": "Re-exploration and hepatico-jejunostomy", "correct": false}, {"label": "D", "text": "MRCP", "correct": false}], "correct_answer": "A. Ultrasound-guided drainage", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A. Ultrasound-guided drainage</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Endoscopic retrograde cholangiopancreatography (ERCP) and stenting - ERCP with stenting is generally reserved for cases where there is a confirmed bile duct injury or obstruction , with the stent helping to facilitate healing and prevent stricture formation.</li><li>• Option B:</li><li>• Endoscopic retrograde cholangiopancreatography (ERCP) and stenting</li><li>• ERCP</li><li>• stenting</li><li>• reserved for cases where there is a confirmed bile duct injury</li><li>• obstruction</li><li>• stent helping to facilitate healing</li><li>• Option C: Re-exploration and hepatico-jejunostomy - Re-exploration is considered when there is a significant bile duct injury , particularly involving the common bile duct or hepatic ducts . Hepatico-jejunostomy might be required for complex or higher injuries but done at a later stage after stabilising.</li><li>• Option C:</li><li>• Re-exploration and hepatico-jejunostomy</li><li>• when there is a significant bile duct injury</li><li>• common bile duct or hepatic ducts</li><li>• Option D: MRCP - Magnetic Resonance Cholangiopancreatography (MRCP) is a non-invasive imaging technique used to delineate the biliary and pancreatic ductal systems and is useful for planning further management if there is uncertainty after ultrasound findings.</li><li>• Option D:</li><li>• MRCP</li><li>• non-invasive imaging technique</li><li>• delineate the biliary and pancreatic ductal systems</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ In a patient presenting with fever and right hypochondrial pain post-cholecystectomy, accompanied by fluid collection on ultrasound , the initial step should be ultrasound-guided drainage . This minimally invasive approach can effectively manage a bile leak, which is a recognized complication after gallbladder surgery. Further diagnostic and therapeutic measures, such as ERCP, MRCP, or surgical intervention, depend on the clinical evolution and findings after the initial drainage.</li><li>➤ fever and right hypochondrial pain post-cholecystectomy,</li><li>➤ fluid collection on ultrasound</li><li>➤ initial step should be ultrasound-guided drainage</li><li>➤ Serious complications after cholecystectomy fall into two major areas: access complications and bile duct injuries. The latter are rare, occurring in approximately 0.5% following laparoscopic cholecystectomy. In the main, biliary injury results from poor dissection and a failure to define the surgical anatomy adequately. The first step following resuscitation and administration of appropriate antibiotics is to undertake urgent USG. This will demonstrate whether there is intra- or extrahepatic ductal dilatation. If a fluid collection is present in the subhepatic space, drainage catheters may be required. These can be inserted under radiological control or, if this expertise is not available, at open operation. The anatomy may need to be defined by MRCP or ERCP. The latter is undertaken when therapeutic maneuver are planned, such as the removal of an obstructing stone or the insertion of a stent across a biliary leak. Small biliary leaks will usually resolve spontaneously, especially if there is no distal obstruction. If the CBD is damaged, the patient should be referred to an appropriate expert for reconstruction.</li><li>➤ Serious complications after cholecystectomy fall into two major areas: access complications and bile duct injuries. The latter are rare, occurring in approximately 0.5% following laparoscopic cholecystectomy. In the main, biliary injury results from poor dissection and a failure to define the surgical anatomy adequately.</li><li>➤ In the main, biliary injury results from poor dissection and a failure to define the surgical anatomy adequately.</li><li>➤ The first step following resuscitation and administration of appropriate antibiotics is to undertake urgent USG. This will demonstrate whether there is intra- or extrahepatic ductal dilatation. If a fluid collection is present in the subhepatic space, drainage catheters may be required. These can be inserted under radiological control or, if this expertise is not available, at open operation.</li><li>➤ The anatomy may need to be defined by MRCP or ERCP. The latter is undertaken when therapeutic maneuver are planned, such as the removal of an obstructing stone or the insertion of a stent across a biliary leak. Small biliary leaks will usually resolve spontaneously, especially if there is no distal obstruction. If the CBD is damaged, the patient should be referred to an appropriate expert for reconstruction.</li><li>➤ Ref: Bailey 28 th Ed. Pg 1251-52</li><li>➤ Ref:</li><li>➤ Bailey 28 th Ed. Pg 1251-52</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "What is the Child-Pugh-Turcotte stage of a patient with Bilirubin 2.5mg%, Albumin 3g%, INR 2, mild ascites and no encephalopathy?", "options": [{"label": "A", "text": "A", "correct": false}, {"label": "B", "text": "B", "correct": true}, {"label": "C", "text": "C", "correct": false}, {"label": "D", "text": "D", "correct": false}], "correct_answer": "B. B", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/screenshot-2024-03-28-181509.jpg"], "explanation": "<p><strong>Ans. B) B</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of the following approaches will provide surgical access to the pancreatic pathologies except?", "options": [{"label": "A", "text": "Through greater omentum", "correct": false}, {"label": "B", "text": "Through retroperitoneum", "correct": false}, {"label": "C", "text": "Through stomach", "correct": false}, {"label": "D", "text": "Through colon", "correct": true}], "correct_answer": "D. Through colon", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Through colon</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• For pancreatic resections: The surgical approach may be through a midline laparotomy, especially if the area involved is around the pancreatic head. The duodenocolic and gastro-colic ligaments (greater omentum) should be divided and the lesser sac opened. Thorough debridement of the dead tissue around the pancreas should be carried out. If the body and tail of the gland are primarily involved, a retroperitoneal approach through a left flank incision may be more appropriate For pseudocyst drainage : A percutaneous trans-gastric cystgastrostomy can be performed under imaging guidance, and a double-pigtail drain placed with one end in the cyst cavity and the other end in the gastric lumen. Surgical drainage involves internally draining the cyst into the gastric or jejunal lumen. Other access approaches:</li><li>• For pancreatic resections: The surgical approach may be through a midline laparotomy, especially if the area involved is around the pancreatic head. The duodenocolic and gastro-colic ligaments (greater omentum) should be divided and the lesser sac opened. Thorough debridement of the dead tissue around the pancreas should be carried out. If the body and tail of the gland are primarily involved, a retroperitoneal approach through a left flank incision may be more appropriate</li><li>• duodenocolic and gastro-colic ligaments (greater omentum) should be divided and the lesser sac opened.</li><li>• retroperitoneal approach</li><li>• For pseudocyst drainage : A percutaneous trans-gastric cystgastrostomy can be performed under imaging guidance, and a double-pigtail drain placed with one end in the cyst cavity and the other end in the gastric lumen. Surgical drainage involves internally draining the cyst into the gastric or jejunal lumen.</li><li>• For pseudocyst drainage</li><li>• trans-gastric</li><li>• Other access approaches:</li><li>• Through lesser omentum Through transverse mesocolon</li><li>• Through lesser omentum</li><li>• Through transverse mesocolon</li><li>• Ref: Bailey 28 th Ed. Pg 1275-77</li><li>• Ref:</li><li>• Bailey 28 th Ed. Pg 1275-77</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is not one of the common features of glucagonoma?", "options": [{"label": "A", "text": "Diabetes", "correct": false}, {"label": "B", "text": "Dermatitis", "correct": false}, {"label": "C", "text": "Diarrhea", "correct": true}, {"label": "D", "text": "Depression", "correct": false}], "correct_answer": "C. Diarrhea", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture43.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C. Diarrhea</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Glucagonoma is associated with the classic presentation of the “4 D’s ”: diabetes, dermatitis, deep vein thrombosis , and depression . Diarrhea is not a common feature of this syndrome . Treatment involves nutritional support, octreotide to manage symptoms, and prophylaxis against thromboembolism, with surgical resection indicated for resectable disease.</li><li>➤ Glucagonoma</li><li>➤ classic presentation of the “4 D’s</li><li>➤ diabetes, dermatitis, deep vein thrombosis</li><li>➤ depression</li><li>➤ Diarrhea</li><li>➤ not a common feature of this syndrome</li><li>➤ It is also characterized by a severe catabolic state with weight loss , depletion of fat and protein stores , and associated vitamin deficiencies. The characteristic skin lesion, a necrolytic migrating erythema, is noted in approximately two thirds of patients and often appears before other symptoms of the syndrome. The cause is believed to be severe amino acid deficiency, although trace element deficiency and general malnutrition probably contribute. These tumors almost always arise in the pancreas with 65% to 75% located in the body or tail, corresponding to the normal distribution of alpha cells in the pancreas. Glucagonomas are malignant in 50% to 80% of cases; 80% of patients with malignant glucagonomas have liver metastases at the time of diagnosis. Treatment begins with medical therapy to improve the patient’s nutritional status with supplemental enteral nutrition. Octreotide is often required in conjunction with enteral nutrition to reverse the catabolic state. Intravenous infusions of amino acids may be required to reverse symptoms and improve dermatitis. Prophylaxis against thromboembolism should be instituted early during hospitalization to prevent perioperative deep vein thrombosis and pulmonary embolism, which occur commonly and are significant causes of morbidity and mortality in these patients. Similar to other PNETs, complete anatomic resection is indicated for resectable disease.</li><li>➤ It is also characterized by a severe catabolic state with weight loss , depletion of fat and protein stores , and associated vitamin deficiencies.</li><li>➤ It is also characterized by a severe catabolic state with weight loss , depletion of fat and protein stores , and associated vitamin deficiencies.</li><li>➤ severe catabolic state with weight loss</li><li>➤ depletion of fat</li><li>➤ protein stores</li><li>➤ vitamin deficiencies.</li><li>➤ The characteristic skin lesion, a necrolytic migrating erythema, is noted in approximately two thirds of patients and often appears before other symptoms of the syndrome. The cause is believed to be severe amino acid deficiency, although trace element deficiency and general malnutrition probably contribute.</li><li>➤ The characteristic skin lesion, a necrolytic migrating erythema, is noted in approximately two thirds of patients and often appears before other symptoms of the syndrome. The cause is believed to be severe amino acid deficiency, although trace element deficiency and general malnutrition probably contribute.</li><li>➤ These tumors almost always arise in the pancreas with 65% to 75% located in the body or tail, corresponding to the normal distribution of alpha cells in the pancreas. Glucagonomas are malignant in 50% to 80% of cases; 80% of patients with malignant glucagonomas have liver metastases at the time of diagnosis.</li><li>➤ These tumors almost always arise in the pancreas with 65% to 75% located in the body or tail, corresponding to the normal distribution of alpha cells in the pancreas. Glucagonomas are malignant in 50% to 80% of cases; 80% of patients with malignant glucagonomas have liver metastases at the time of diagnosis.</li><li>➤ Treatment begins with medical therapy to improve the patient’s nutritional status with supplemental enteral nutrition. Octreotide is often required in conjunction with enteral nutrition to reverse the catabolic state.</li><li>➤ Treatment begins with medical therapy to improve the patient’s nutritional status with supplemental enteral nutrition. Octreotide is often required in conjunction with enteral nutrition to reverse the catabolic state.</li><li>➤ Intravenous infusions of amino acids may be required to reverse symptoms and improve dermatitis. Prophylaxis against thromboembolism should be instituted early during hospitalization to prevent perioperative deep vein thrombosis and pulmonary embolism, which occur commonly and are significant causes of morbidity and mortality in these patients.</li><li>➤ Intravenous infusions of amino acids may be required to reverse symptoms and improve dermatitis. Prophylaxis against thromboembolism should be instituted early during hospitalization to prevent perioperative deep vein thrombosis and pulmonary embolism, which occur commonly and are significant causes of morbidity and mortality in these patients.</li><li>➤ Similar to other PNETs, complete anatomic resection is indicated for resectable disease.</li><li>➤ Similar to other PNETs, complete anatomic resection is indicated for resectable disease.</li><li>➤ Ref : Sabiston Textbook of Surgery 20th Edition Page 957</li><li>➤ Ref : Sabiston Textbook of Surgery 20th Edition Page 957</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of the following cases can benefit from TIPSS except?", "options": [{"label": "A", "text": "Portal vein thrombosis resulting in portal HTN", "correct": true}, {"label": "B", "text": "Refractory Ascites due to portal HTN", "correct": false}, {"label": "C", "text": "Bleeding varices despite endoscopic management", "correct": false}, {"label": "D", "text": "As a bridge to liver transplant", "correct": false}], "correct_answer": "A. Portal vein thrombosis resulting in portal HTN", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A. Portal vein thrombosis resulting in portal hypertension.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Refractory Ascites due to portal hypertension Patients with refractory ascites due to portal hypertension can benefit from TIPSS , as the procedure reduces portal pressure and can help control ascites.</li><li>• Option B: Refractory Ascites due to portal hypertension</li><li>• refractory ascites</li><li>• portal hypertension</li><li>• benefit from TIPSS</li><li>• Option C: Bleeding varices despite endoscopic management TIPSS is a treatment option for patients who continue to have variceal bleeding despite endoscopic treatment methods like banding or sclerotherapy.</li><li>• Option C: Bleeding varices despite endoscopic management</li><li>• treatment option for patients who continue to have variceal bleeding</li><li>• Option D: As a bridge to liver transplant TIPSS can be used as a bridge to liver transplantation by managing complications of portal hypertension , such as variceal bleeding or refractory ascites, until a liver transplant can be performed.</li><li>• Option D: As a bridge to liver transplant</li><li>• used as a bridge to liver transplantation</li><li>• managing complications of portal hypertension</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Portal vein thrombosis is a contraindication for TIPSS because it precludes the formation of a shunt , which is essential for the procedure's success .</li><li>➤ Portal vein thrombosis</li><li>➤ contraindication for TIPSS because it precludes the formation of a shunt</li><li>➤ procedure's success</li><li>➤ TIPSS has replaced surgical portocaval shunt and is now accepted as the preferred method for treating refractory portal hypertension. A TIPSS is inserted under local anesthesia, analgesia and sedation using fluoroscopic guidance and ultrasonography. Via the internal jugular vein, superior vena cava and hepatic vein, a guidewire is inserted through the hepatic parenchyma into a branch of the portal vein. The tract is dilated; a metallic stent is then inserted and expanded, forming a portal venous channel. A satisfactory drop in portal venous pressure is usually associated with good control of the variceal hemorrhage. The main contraindication to TIPSS is portal vein occlusion.</li><li>➤ TIPSS has replaced surgical portocaval shunt and is now accepted as the preferred method for treating refractory portal hypertension. A TIPSS is inserted under local anesthesia, analgesia and sedation using fluoroscopic guidance and ultrasonography. Via the internal jugular vein, superior vena cava and hepatic vein, a guidewire is inserted through the hepatic parenchyma into a branch of the portal vein. The tract is dilated; a metallic stent is then inserted and expanded, forming a portal venous channel. A satisfactory drop in portal venous pressure is usually associated with good control of the variceal hemorrhage. The main contraindication to TIPSS is portal vein occlusion.</li><li>➤ The main contraindication to TIPSS is portal vein occlusion.</li><li>➤ Ref : Bailey 28 th Ed. Pg 1205</li><li>➤ Ref : Bailey 28 th Ed. Pg 1205</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All the following are true about insulinoma except?", "options": [{"label": "A", "text": "Most likely malignant", "correct": true}, {"label": "B", "text": "Symptoms are often due to release of catecholamines.", "correct": false}, {"label": "C", "text": "Somatostatin receptor scintigraphy is not very sensitive", "correct": false}, {"label": "D", "text": "Surgery of choice is enucleation", "correct": false}], "correct_answer": "A. Most likely malignant", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A. Most likely malignant.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Symptoms are often due to the release of catecholamines. This is correct . When insulinomas cause hypoglycemia, the body responds by releasing catecholamines, leading to symptoms such as sweating, weakness, hunger, tremors, nausea, anxiety, and palpitations.</li><li>• Option B: Symptoms are often due to the release of catecholamines.</li><li>• correct</li><li>• Option C: Somatostatin receptor scintigraphy is not very sensitive. This statement is correct. Somatostatin receptor scintigraphy may not be very sensitive for detecting insulinomas, as these tumors may not always express somatostatin receptors in sufficient quantities to be detected by this imaging method.</li><li>• Option C: Somatostatin receptor scintigraphy is not very sensitive.</li><li>• correct.</li><li>• Option D: Surgery of choice is enucleation. This is correct . The surgical treatment of choice for insulinomas, especially if they are benign and without signs of invasion, is enucleation.</li><li>• Option D: Surgery of choice is enucleation.</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Insulinomas are most often benign , with clinical features including symptoms of neuroglycopenia and catecholamine release . The surgery of choice for localized, benign insulinomas is enucleation. Somatostatin receptor scintigraphy may not be sensitive for detecting insulinomas.</li><li>➤ Insulinomas</li><li>➤ most often benign</li><li>➤ clinical features including symptoms of neuroglycopenia</li><li>➤ catecholamine release</li><li>➤ localized, benign insulinomas is enucleation.</li><li>➤ Clinical features-</li><li>➤ Clinical features-</li><li>➤ Symptoms of neuroglycopenia which classically manifest while fasting or during exercise or sometimes post-prandially Sweating, weakness, hunger, tremors, nausea, anxiety, palpitations all due to release of catecholamines. Whipple’s triad- Symptoms induced by fasting; Hypoglycaemia at the time of symptoms; Symptoms relieved by administration of glucose.</li><li>➤ Symptoms of neuroglycopenia which classically manifest while fasting or during exercise or sometimes post-prandially</li><li>➤ Sweating, weakness, hunger, tremors, nausea, anxiety, palpitations all due to release of catecholamines.</li><li>➤ Whipple’s triad-</li><li>➤ Symptoms induced by fasting;</li><li>➤ Hypoglycaemia at the time of symptoms;</li><li>➤ Symptoms relieved by administration of glucose.</li><li>➤ Investigations –</li><li>➤ Investigations</li><li>➤ –</li><li>➤ 72 hour fasting which will show symptoms along with elevated insulin and high C-peptide. If this test is negative and the suspicion of insulinoma is high, a prolonged oral glucose tolerance test is done. After a positive fast test, a CT or MRI is performed.</li><li>➤ 72 hour fasting which will show symptoms along with elevated insulin and high C-peptide. If this test is negative and the suspicion of insulinoma is high, a prolonged oral glucose tolerance test is done.</li><li>➤ After a positive fast test, a CT or MRI is performed.</li><li>➤ Treatment –</li><li>➤ Treatment</li><li>➤ –</li><li>➤ Medical - diazoxide, somatostatin analogues Surgical - enucleation</li><li>➤ Medical - diazoxide, somatostatin analogues</li><li>➤ Surgical - enucleation</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 906</li><li>➤ Ref</li><li>➤ :</li><li>➤ Bailey</li><li>➤ and Love’s Short Practice of Surgery 28th Edition Page 906</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old male, who is a known case of cirrhosis of liver, presented to the casualty with painless profuse hematemesis. Which of these is not a component of his management?", "options": [{"label": "A", "text": "Vitamin K injection", "correct": false}, {"label": "B", "text": "Resuscitation with PRBCs and FFP", "correct": false}, {"label": "C", "text": "Intravenous Octreotide", "correct": false}, {"label": "D", "text": "Furosemide", "correct": true}], "correct_answer": "D. Furosemide", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D. Furosemide</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Vitamin K injection : Vitamin K is often given to patients with liver disease to help with clotting factors .</li><li>• Option A. Vitamin K injection</li><li>• liver disease to help with clotting factors</li><li>• Option B. Resuscitation with PRBCs and FFP (packed red blood cells and fresh frozen plasma) : This is an essential component of management to replace blood loss and correct coagulopathy , which is common in cirrhosis-related bleeding.</li><li>• Option B. Resuscitation with PRBCs and FFP (packed red blood cells and fresh frozen plasma)</li><li>• essential component of management to replace blood loss</li><li>• correct coagulopathy</li><li>• Option C. Intravenous Octreotide : Octreotide is a medication used to reduce portal pressure by causing splanchnic vasoconstriction and can help control bleeding in cirrhotic patients with variceal bleeding. It's a critical part of the management.</li><li>• Option C. Intravenous Octreotide</li><li>• reduce portal pressure by causing splanchnic vasoconstriction</li><li>• control bleeding in cirrhotic</li><li>• So, the option that is not a component of the immediate management for a cirrhotic patient with painless profuse hematemesis is Furosemide (D).</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Patient should be admitted in ICU , two large-bore peripheral cannula and resuscitation commenced , ideally with blood . Liver function tests will reveal underlying liver disease and a coagulation profile will identify any coagulopathy. Hypervolemia may increase portal pressure and exacerbate bleeding. Ten milligrams of vitamin K are administered intravenously while a coagulopathy requires FFP and activation of a major transfusion protocol. Thrombocytopenia secondary to hypersplenism is treated if the platelet count is less than 50,000. Treatment protocols include the use of splanchnic vasoconstrictors, such as terlipressin, octreotide and somatostatin, and prophylactic antibiotics. When bleeding continues treatment options are sclerotherapy, banding, balloon tamponade and TIPSS. The use of esophageal balloons should be avoided, which is usually possible when experienced endoscopists are available. As soon as the patient is hemodynamically stable the diagnosis should be confirmed endoscopically as 30% will have a non-variceal source of bleeding. Variceal bleeding is often associated with hepatic encephalopathy and endotracheal intubation may be required prior to endoscopy to protect the airway and prevent aspiration.</li><li>• Patient should be admitted in ICU , two large-bore peripheral cannula and resuscitation commenced , ideally with blood . Liver function tests will reveal underlying liver disease and a coagulation profile will identify any coagulopathy. Hypervolemia may increase portal pressure and exacerbate bleeding.</li><li>• admitted in ICU</li><li>• two large-bore peripheral cannula</li><li>• resuscitation commenced</li><li>• blood</li><li>• Liver function tests</li><li>• liver disease and a coagulation profile</li><li>• Ten milligrams of vitamin K are administered intravenously while a coagulopathy requires FFP and activation of a major transfusion protocol. Thrombocytopenia secondary to hypersplenism is treated if the platelet count is less than 50,000.</li><li>• Ten milligrams of vitamin K are administered intravenously</li><li>• Treatment protocols include the use of splanchnic vasoconstrictors, such as terlipressin, octreotide and somatostatin, and prophylactic antibiotics.</li><li>• When bleeding continues treatment options are sclerotherapy, banding, balloon tamponade and TIPSS. The use of esophageal balloons should be avoided, which is usually possible when experienced endoscopists are available.</li><li>• As soon as the patient is hemodynamically stable the diagnosis should be confirmed endoscopically as 30% will have a non-variceal source of bleeding. Variceal bleeding is often associated with hepatic encephalopathy and endotracheal intubation may be required prior to endoscopy to protect the airway and prevent aspiration.</li><li>• Ref : Bailey 28th Ed. Pg 1204</li><li>• Ref</li><li>• : Bailey 28th Ed. Pg 1204</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the incorrect statement regarding liver anatomy?", "options": [{"label": "A", "text": "Cantlie’s line passes through the GB fossa", "correct": false}, {"label": "B", "text": "Cantlie's line divides the liver functionally into two lobes", "correct": false}, {"label": "C", "text": "The left lobe of the liver has 4 segments and the right lobe has 3", "correct": true}, {"label": "D", "text": "The caudate lobe is drained by the middle hepatic vein", "correct": false}], "correct_answer": "C. The left lobe of the liver has 4 segments and the right lobe has 3", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture11.jpg"], "explanation": "<p><strong>Ans. C) The left lobe of the liver has 4 segments and the right lobe has 3 segments.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A and B: Cantlie’s line passes through the GB fossa. Cantlie’s line divides the liver functionally into two lobes. Cantlie’s line , or the principal plane , runs from the gallbladder fossa to the inferior vena cava (IVC) and is used to divide the liver into right and left lobes functionally. This statement is correct.</li><li>• Option A and B: Cantlie’s line passes through the GB fossa. Cantlie’s line divides the liver functionally into two lobes.</li><li>• Cantlie’s line</li><li>• principal plane</li><li>• gallbladder fossa to the inferior vena cava</li><li>• Option D: The caudate lobe is drained by the middle hepatic vein . This statement is generally considered true . The caudate lobe (segment I) is unique in that it receives blood flow from both the right- and left-sided portal venous branches and is drained by multiple small hepatic veins, including branches of the middle hepatic vein.</li><li>• Option D: The caudate lobe is drained by the middle hepatic vein</li><li>• true</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The right lobe of the liver has four segments , while the left lobe has three , with Cantlie's line dividing the liver into these two functional lobes , and the caudate lobe is drained by the middle hepatic vein .</li><li>➤ right lobe of the liver has four segments</li><li>➤ left lobe has three</li><li>➤ Cantlie's line dividing the liver into these two functional lobes</li><li>➤ caudate lobe is drained by the middle hepatic vein</li><li>➤ The liver is composed of eight segments, each supplied by terminal branches of the portal vein (80% of the blood flow) and hepatic artery (20%) and drained by bile ducts and hepatic veins. The Cantlie’s line is an imaginary line that divides the liver functionally into 2 lobes. It represents the GB fossa, the IVC and the middle hepatic vein. Venous drainage: right hepatic veins drain the right lobe of liver, the middle hepatic vein drains the caudate lobe and the left hepatic veins drain the left lobe.</li><li>➤ The liver is composed of eight segments, each supplied by terminal branches of the portal vein (80% of the blood flow) and hepatic artery (20%) and drained by bile ducts and hepatic veins. The Cantlie’s line is an imaginary line that divides the liver functionally into 2 lobes. It represents the GB fossa, the IVC and the middle hepatic vein.</li><li>➤ The Cantlie’s line is an imaginary line that divides the liver functionally into 2 lobes. It represents the GB fossa, the IVC and the middle hepatic vein.</li><li>➤ Venous drainage: right hepatic veins drain the right lobe of liver, the middle hepatic vein drains the caudate lobe and the left hepatic veins drain the left lobe.</li><li>➤ Ref: Bailey 28 th Ed. Pg 1192</li><li>➤ Ref: Bailey 28 th Ed. Pg 1192</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "What is the most common vascular anomaly of the liver?", "options": [{"label": "A", "text": "Independent origin of the right and left hepatic arteries from the celiac axis", "correct": false}, {"label": "B", "text": "Replaced left hepatic artery arising from superior mesenteric artery", "correct": false}, {"label": "C", "text": "Replaced right hepatic artery arising from the superior mesenteric artery", "correct": true}, {"label": "D", "text": "Replaced right hepatic artery arising from left gastric artery", "correct": false}], "correct_answer": "C. Replaced right hepatic artery arising from the superior mesenteric artery", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture12.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture13.jpg"], "explanation": "<p><strong>Ans. C) Replaced right hepatic artery arising from superior mesenteric artery</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Independent origin of the right and left hepatic arteries from the celiac axis. Normally, the c ommon hepatic artery arises from the celiac trunk and gives rise to the right and left hepatic arteries . Independent origin of both hepatic arteries directly from the celiac axis is less common.</li><li>• Option A: Independent origin of the right and left hepatic arteries from the celiac axis.</li><li>• ommon hepatic artery</li><li>• celiac trunk</li><li>• gives rise to the right and left hepatic arteries</li><li>• Option B: Replaced left hepatic artery arising from superior mesenteric artery. A replaced left hepatic artery typically arises from the left gastric artery , not the superior mesenteric artery. This anomaly is less common compared to the right hepatic artery anomalies.</li><li>• Option B: Replaced left hepatic artery arising from superior mesenteric artery.</li><li>• replaced left hepatic artery</li><li>• arises from the left gastric artery</li><li>• Option D: Replaced right hepatic artery arising from left gastric artery. The right hepatic artery typically does not arise from the left gastric artery . When it is \"replaced,\" it more commonly originates from the superior mesenteric artery.</li><li>• Option D: Replaced right hepatic artery arising from left gastric artery.</li><li>• right hepatic artery</li><li>• does not arise from the left gastric artery</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most common vascular anomaly of the liver is the presence of a replaced right hepatic artery arising from the superior mesenteric artery, which is an important consideration in hepatic surgeries and liver transplantation due to its implications on surgical planning and postoperative outcomes.</li><li>➤ most common vascular anomaly of the liver</li><li>➤ presence of a replaced right hepatic artery</li><li>➤ superior mesenteric artery,</li><li>➤ The arterial blood supply is variable in origin and course but in most individuals is derived from the coeliac trunk , which usually divides into left gastric , common hepatic and splenic arteries. After supplying the gastroduodenal artery, the hepatic artery branches at a variable level to produce the right and left hepatic arteries, the larger right branch supplying the right lobe.</li><li>➤ The arterial blood supply is variable in origin and course but in most individuals is derived from the coeliac trunk , which usually divides into left gastric , common hepatic and splenic arteries.</li><li>➤ arterial blood supply</li><li>➤ variable in origin</li><li>➤ course</li><li>➤ most individuals is derived from the coeliac trunk</li><li>➤ divides into left gastric</li><li>➤ hepatic and splenic arteries.</li><li>➤ After supplying the gastroduodenal artery, the hepatic artery branches at a variable level to produce the right and left hepatic arteries, the larger right branch supplying the right lobe.</li><li>➤ Normal arterial anatomy of liver</li><li>➤ The right lobe may be partly or completely supplied by a right hepatic artery arising directly from the superior mesenteric artery running to the liver on the posterior wall of the bile duct after passing behind the uncinate process and head of the pancreas. Similarly, the left lobe artery may be augmented or replaced by a branch of the left gastric artery running in the lesser omentum from the lesser curve of the stomach. Surgical significance: Replaced right hepatic artery is a beneficial variant in living donors of right liver. The common postoperative complication in liver transplantation is hepatic artery thrombosis because of shorter and thinner hepatic artery graft but replaced right hepatic artery in liver transplant donor provides a longer and larger graft thus reducing chances of thrombosis. On the other hand, replaced right artery in the recipient increases the risk of hepatic artery complications after transplantation due to the small caliber of the common hepatic artery.</li><li>➤ The right lobe may be partly or completely supplied by a right hepatic artery arising directly from the superior mesenteric artery running to the liver on the posterior wall of the bile duct after passing behind the uncinate process and head of the pancreas.</li><li>➤ The right lobe may be partly or completely supplied by a right hepatic artery arising directly from the superior mesenteric artery running to the liver on the posterior wall of the bile duct after passing behind the uncinate process and head of the pancreas.</li><li>➤ Similarly, the left lobe artery may be augmented or replaced by a branch of the left gastric artery running in the lesser omentum from the lesser curve of the stomach.</li><li>➤ Surgical significance: Replaced right hepatic artery is a beneficial variant in living donors of right liver. The common postoperative complication in liver transplantation is hepatic artery thrombosis because of shorter and thinner hepatic artery graft but replaced right hepatic artery in liver transplant donor provides a longer and larger graft thus reducing chances of thrombosis.</li><li>➤ On the other hand, replaced right artery in the recipient increases the risk of hepatic artery complications after transplantation due to the small caliber of the common hepatic artery.</li><li>➤ Ref: Bailey 28 th Ed. Pg 1192, 1210. Sabiston 21 st Ed. Pg 1432-33</li><li>➤ Ref:</li><li>➤ Bailey 28 th Ed. Pg 1192, 1210. Sabiston 21 st Ed. Pg 1432-33</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 35-year-old male had visited India a couple of months back. He had a history of bloody diarrhea for a few days on returning, which subsided on its own. He now presents with right upper abdominal pain, low grade fever, and weight loss. On examination, the patient shows pallor and tender hepatomegaly. Following image is obtained. What is incorrect about this disease?", "options": [{"label": "A", "text": "Organism typically affects the colon", "correct": false}, {"label": "B", "text": "The life cycle is partly in sheep and partly in man", "correct": true}, {"label": "C", "text": "The treatment of choice is metronidazole with chloroquine and diloxanide furoate", "correct": false}, {"label": "D", "text": "The aspirate shows “sterile pus” on microscopy", "correct": false}], "correct_answer": "B. The life cycle is partly in sheep and partly in man", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture15.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B) The life cycle is partly in sheep and partly in man.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Organism typically affects the colon. This is correct . Entamoeba histolytica primarily infects the colon and can cause amebic dysentery, flask shaped ulcers in cecum or sigmoid colon</li><li>• Option A: Organism typically affects the colon.</li><li>• correct</li><li>• Option C: The treatment of choice is metronidazole with chloroquine and diloxanide furoate. This is correct. Metronidazole is the drug of choice for invasive amoebiasis, and diloxanide furoate is used as a luminal agent to eliminate intraluminal cysts. Chloroquine may be used adjunctively for the treatment of amebic liver abscesses, particularly when metronidazole alone is insufficient.</li><li>• Option C: The treatment of choice is metronidazole with chloroquine and diloxanide furoate.</li><li>• correct.</li><li>• Option D: The aspirate shows “sterile pus” on microscopy. This is correct . Aspirates from an amebic liver abscess typically do not show bacteria when cultured, hence the term \"sterile pus.\" The aspirate is often described as looking like \"anchovy sauce\" due to the presence of necrotic liver tissue and blood.</li><li>• Option D: The aspirate shows “sterile pus” on microscopy.</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Entamoeba histolytica is the causative agent of amebic liver abscess , with a life cycle that occurs exclusively in humans, not sheep . The treatment includes metronidazole , often combined with other agents like chloroquine and diloxanide furoate , and the condition is characterized by \"sterile pus\" in the liver abscess aspirate.</li><li>➤ Entamoeba histolytica</li><li>➤ causative agent of amebic liver abscess</li><li>➤ life cycle that occurs exclusively in humans, not sheep</li><li>➤ metronidazole</li><li>➤ chloroquine and diloxanide furoate</li><li>➤ characterized by \"sterile pus\" in the liver abscess aspirate.</li><li>➤ The organism enters the gut through food or water contaminated with the cyst. In the small bowel, the cysts hatch and a large number of trophozoites are released and carried to the colon, where flask-shaped ulcers form in the submucosa. The trophozoites multiply, ultimately forming cysts, which either enter the portal circulation or are passed in the faeces as an infective form that infects other humans as a result of insanitary conditions. Having entered the portal circulation, the trophozoites are filtered and trapped in the interlobular veins of the liver. They multiply in the portal triads, causing focal infarction of hepatocytes and liquefactive necrosis as a result of proteolytic enzymes produced by the trophozoites. The areas of necrosis eventually coalesce to form the abscess cavity. The typical patient with an amoebic liver abscess is a young adult male with a history of insidious onset of non-specific symptoms, such as abdominal pain, anorexia, fever, night sweats, malaise, cough and weight loss. These symptoms gradually progress to more specific symptoms of pain in the right upper abdomen and right shoulder tip, hiccoughs and a non-productive cough. A past history of bloody diarrhoea or travel to an endemic area raises the index of suspicion. The abscess cavity contains chocolate colored, odorless, ‘anchovy sauce’-like fluid that is a mixture of necrotic liver tissue and blood. On ultrasonography, an abscess cavity in the liver is seen as a hypoechoic or anechoic lesion with ill-defined borders; internal echoes suggest necrotic material or debris. The investigation is very accurate and is used for aspiration, both diagnostic and therapeutic. When there is doubt about the diagnosis, a computed tomography (CT) scan may be helpful. Diagnostic aspiration is of limited value except for establishing the typical colour of the aspirate, which is sterile and odorless unless it is secondarily infected Medical treatment is very effective and should be the first choice in the elective situation, with surgery being reserved for complications.</li><li>➤ The organism enters the gut through food or water contaminated with the cyst. In the small bowel, the cysts hatch and a large number of trophozoites are released and carried to the colon, where flask-shaped ulcers form in the submucosa. The trophozoites multiply, ultimately forming cysts, which either enter the portal circulation or are passed in the faeces as an infective form that infects other humans as a result of insanitary conditions.</li><li>➤ carried to the colon, where flask-shaped ulcers form in the submucosa.</li><li>➤ Having entered the portal circulation, the trophozoites are filtered and trapped in the interlobular veins of the liver. They multiply in the portal triads, causing focal infarction of hepatocytes and liquefactive necrosis as a result of proteolytic enzymes produced by the trophozoites. The areas of necrosis eventually coalesce to form the abscess cavity.</li><li>➤ The typical patient with an amoebic liver abscess is a young adult male with a history of insidious onset of non-specific symptoms, such as abdominal pain, anorexia, fever, night sweats, malaise, cough and weight loss. These symptoms gradually progress to more specific symptoms of pain in the right upper abdomen and right shoulder tip, hiccoughs and a non-productive cough. A past history of bloody diarrhoea or travel to an endemic area raises the index of suspicion.</li><li>➤ The abscess cavity contains chocolate colored, odorless, ‘anchovy sauce’-like fluid that is a mixture of necrotic liver tissue and blood.</li><li>➤ On ultrasonography, an abscess cavity in the liver is seen as a hypoechoic or anechoic lesion with ill-defined borders; internal echoes suggest necrotic material or debris. The investigation is very accurate and is used for aspiration, both diagnostic and therapeutic. When there is doubt about the diagnosis, a computed tomography (CT) scan may be helpful. Diagnostic aspiration is of limited value except for establishing the typical colour of the aspirate, which is sterile and odorless unless it is secondarily infected</li><li>➤ Diagnostic aspiration is of limited value except for establishing the typical colour of the aspirate, which is sterile and odorless unless it is secondarily infected</li><li>➤ Medical treatment is very effective and should be the first choice in the elective situation, with surgery being reserved for complications.</li><li>➤ Ref: Bailey 28 th Ed. Pg 66-68</li><li>➤ Ref: Bailey 28 th Ed. Pg 66-68</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A sheep farmer presented to the hospital with a history of pain in the upper part of the abdomen. After a detailed clinical, laboratory, and radiological investigation, a 5 cm single hydatid cyst was found in the right lobe of the liver. The surgeon decides to perform a percutaneous aspiration, injection, and respiration (PAIR) of the cyst. All of the following can be used as scolicidal agents in this procedure except:", "options": [{"label": "A", "text": "Formalin", "correct": true}, {"label": "B", "text": "Cetrimide", "correct": false}, {"label": "C", "text": "Hypertonic saline", "correct": false}, {"label": "D", "text": "Polyvinylpyrrolidone iodine", "correct": false}], "correct_answer": "A. Formalin", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Formalin</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Cetrimide. Cetrimide is an antiseptic agent that can be used as a scolicidal agent during the PAIR procedure to kill the protoscolices of the Echinococcus parasite and prevent secondary hydatidosis.</li><li>• Option B: Cetrimide.</li><li>• antiseptic agent</li><li>• used as a scolicidal agent during the PAIR procedure</li><li>• kill the protoscolices of the Echinococcus parasite</li><li>• Option C: Hypertonic Saline. Hypertonic saline solution is commonly used as a scolicidal agent due to its osmotic effect , which can effectively kill the protoscolices during the PAIR procedure .</li><li>• Option C: Hypertonic Saline.</li><li>• used as a scolicidal agent due to its osmotic effect</li><li>• effectively kill the protoscolices during the PAIR procedure</li><li>• Option D: Polyvinylpyrrolidone Iodine. Polyvinylpyrrolidone iodine, commonly known as povidone-iodine , is an iodophor solution with antiseptic properties and can be used as a scolicidal agent during the PAIR procedure.</li><li>• Option D: Polyvinylpyrrolidone Iodine.</li><li>• commonly known as povidone-iodine</li><li>• iodophor solution with antiseptic properties</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ When performing the PAIR procedure for a hydatid cyst , scolicidal agents such as hypertonic saline, cetrimide, and povidone-iodine are used to prevent dissemination of the parasite, whereas formalin is contraindicated due to the risk of causing sclerosing cholangitis .</li><li>➤ performing the PAIR procedure for a hydatid cyst</li><li>➤ scolicidal agents</li><li>➤ hypertonic saline, cetrimide, and povidone-iodine are used</li><li>➤ dissemination of the parasite,</li><li>➤ formalin is contraindicated due to the risk of causing sclerosing cholangitis</li><li>➤ Formalin is not used as a scolicidal agent since it causes sclerosing cholangitis.</li><li>➤ Formalin is not used as a scolicidal agent</li><li>➤ sclerosing cholangitis.</li><li>➤ Scolicidal agents (used to avoid dissemination of parasite during surgery)</li><li>➤ Hypertonic saline (15-20%) Cetrimide Alcohol (75-95%) Povidone-iodine (5-10%)</li><li>➤ Hypertonic saline (15-20%)</li><li>➤ Cetrimide</li><li>➤ Alcohol (75-95%)</li><li>➤ Povidone-iodine (5-10%)</li><li>➤ Ref: Bailey 28 th Ed. Pg 76</li><li>➤ Ref:</li><li>➤ Bailey 28 th Ed. Pg 76</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of these are components of Barcelona Clinic for Liver Cancer (BCLC) staging except:", "options": [{"label": "A", "text": "Performance status", "correct": false}, {"label": "B", "text": "Portal Vein invasion", "correct": false}, {"label": "C", "text": "Number of tumors", "correct": false}, {"label": "D", "text": "AFP (alpha feto-protein)", "correct": true}], "correct_answer": "D. AFP (alpha feto-protein)", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) AFP</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Performance Status. The Eastern Cooperative Oncology Group (ECOG) performance status is a component of the BCLC staging system , assessing how the disease affects the patient's daily living abilities.</li><li>• Option A: Performance Status.</li><li>• Eastern Cooperative Oncology Group</li><li>• performance status</li><li>• component of the BCLC staging system</li><li>• Option B: Portal Vein Invasion. Portal vein (PV) invasion or thrombosis is a critical factor in the BCLC staging system , indicating more advanced disease and influencing treatment decisions.</li><li>• Option B: Portal Vein Invasion.</li><li>• thrombosis is a critical factor in the BCLC staging system</li><li>• Option C: Number of Tumors. The number of tumors, their size, and the presence of extrahepatic spread are part of the TNM (Tumor, Node, Metastasis) classification, which is incorporated into the BCLC staging.</li><li>• Option C: Number of Tumors.</li><li>• their size, and the presence of extrahepatic spread are part of the TNM</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In the BCLC staging system for hepatocellular carcinoma, important components include the TNM staging, portal vein invasion, Child-Pugh score, and ECOG performance status , while AFP is not included in the staging criteria.</li><li>➤ BCLC staging system for hepatocellular carcinoma,</li><li>➤ TNM staging, portal vein invasion, Child-Pugh score, and ECOG performance status</li><li>➤ The Barcelona clinic includes .</li><li>➤ The Barcelona clinic includes</li><li>➤ TNM staging (size, no. of tumors, metastasis) PV invasion Child Pugh score ECOG: performance status</li><li>➤ TNM staging (size, no. of tumors, metastasis)</li><li>➤ PV invasion</li><li>➤ Child Pugh score</li><li>➤ ECOG: performance status</li><li>➤ The Cancer of the Liver Italian Program (CLIP) score is used for prognostic staging of HCC and includes variables such as tumor morphology , AFP levels , Child-Pugh stage , and portal vein thrombosis.</li><li>➤ Cancer of the Liver Italian Program</li><li>➤ score</li><li>➤ prognostic staging of HCC</li><li>➤ variables such as tumor morphology</li><li>➤ AFP levels</li><li>➤ Child-Pugh stage</li><li>➤ Ref: Bailey 28 th Ed. Pg 1215</li><li>➤ Ref: Bailey 28 th Ed. Pg 1215</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "According to BCLC, patient with multi-lobular liver cancer with good performance status and Child’s A disease should be managed by:", "options": [{"label": "A", "text": "Wide excision", "correct": false}, {"label": "B", "text": "Liver Transplant", "correct": false}, {"label": "C", "text": "TACE (trans-arterial chemoembolization)", "correct": true}, {"label": "D", "text": "Sorafenib", "correct": false}], "correct_answer": "C. TACE (trans-arterial chemoembolization)", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C. TACE (trans-arterial chemoembolization)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Wide excision. Wide excision, or surgical resection , is typically recommended for patients with early-stage HCC (stage 0–A), who have a single tumor and good liver function , without evidence of vascular invasion or extrahepatic spread.</li><li>• Option A: Wide excision.</li><li>• surgical resection</li><li>• patients with early-stage HCC</li><li>• single tumor and good liver function</li><li>• Option B: Liver Transplant. Liver transplantation is considered for patients with early-stage HCC (stage 0–A) who meet specific criteria , such as the Milan criteria (single HCC ≤ 5 cm or up to 3 nodules each ≤ 3 cm), and no evidence of extrahepatic disease or vascular invasion.</li><li>• Option B: Liver Transplant.</li><li>• considered for patients with early-stage HCC</li><li>• meet specific criteria</li><li>• Milan criteria</li><li>• Option D: Sorafenib. Sorafenib is an oral tyrosine kinase inhibitor used for patients with advanced HCC (stage C) that has spread or cannot be treated with surgery or TACE . This is suitable for patients with vascular invasion or extrahepatic disease and good performance status.</li><li>• Option D: Sorafenib.</li><li>• oral tyrosine kinase inhibitor</li><li>• patients with advanced HCC</li><li>• spread or cannot be treated with surgery or TACE</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In the BCLC staging system for HCC , patients with multinodular, non-early-stage tumors and preserved liver function (Child’s A) are typically managed with trans-arterial chemoembolization (TACE), reflecting a balance between therapeutic intervention and the patient’s liver function reserve.</li><li>➤ BCLC staging system for HCC</li><li>➤ multinodular, non-early-stage tumors</li><li>➤ preserved liver function</li><li>➤ managed with trans-arterial chemoembolization</li><li>➤ The Barcelona Clinic Liver Group staging system for the management of hepatocellular carcinoma (HCC).</li><li>➤ Barcelona Clinic Liver Group staging system</li><li>➤ management of hepatocellular carcinoma</li><li>➤ Patients with asymptomatic early tumors (stage 0–A) are candidates for curative therapies (resection, transplantation or local ablation). Asymptomatic patients with multinodular HCC (stage B) are suitable for chemoembolization (TACE) Patients with advanced symptomatic tumors and/or an invasive tumoral pattern (stage C) are candidates for Sorafenib. End-stage disease (stage D) includes patients with grim prognosis who should be treated by best supportive care</li><li>➤ Patients with asymptomatic early tumors (stage 0–A) are candidates for curative therapies (resection, transplantation or local ablation).</li><li>➤ Asymptomatic patients with multinodular HCC (stage B) are suitable for chemoembolization (TACE)</li><li>➤ multinodular HCC (stage B)</li><li>➤ Patients with advanced symptomatic tumors and/or an invasive tumoral pattern (stage C) are candidates for Sorafenib.</li><li>➤ End-stage disease (stage D) includes patients with grim prognosis who should be treated by best supportive care</li><li>➤ Ref: Bailey 28 th Ed. Pg 1215</li><li>➤ Ref: Bailey 28 th Ed. Pg 1215</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is incorrect about gastrinoma?", "options": [{"label": "A", "text": "Presents with ulcers at atypical locations", "correct": false}, {"label": "B", "text": "Metastasis at time of presentation is extremely rare", "correct": true}, {"label": "C", "text": "Majority of the tumours are seen within the duodenum", "correct": false}, {"label": "D", "text": "Proton pump inhibitors are the first line agents in medical management", "correct": false}], "correct_answer": "B. Metastasis at time of presentation is extremely rare", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture42.jpg"], "explanation": "<p><strong>Ans. B. Metastasis at time of presentation is extremely rare</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Presents with ulcers at atypical locations. This is correct . Patients with gastrinoma often present with peptic ulcers in atypical locations like D2/D3/D4, jejunum due to high levels of gastrin leading to excessive gastric acid secretion.</li><li>• Option A: Presents with ulcers at atypical locations.</li><li>• correct</li><li>• Option C: Majority of the tumors are seen within the duodenum. This is correct . While gastrinomas can occur both within and outside the pancreas, the majority are found within the duodenum, particularly within the area known as the gastrinoma triangle.</li><li>• Option C: Majority of the tumors are seen within the duodenum.</li><li>• correct</li><li>• Option D: Proton pump inhibitors are the first-line agents in medical management. This is correct . Proton pump inhibitors (PPIs) are the mainstay of medical treatment for gastrinoma, as they effectively reduce gastric acid secretion and manage symptoms.</li><li>• Option D: Proton pump inhibitors are the first-line agents in medical management.</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Gastrinomas are characterized by peptic ulcers in atypical locations and are often metastatic at presentation . The majority are located within the duodenum , and PPIs are the first-line medical management .</li><li>➤ Gastrinomas</li><li>➤ peptic ulcers in atypical locations</li><li>➤ often metastatic at presentation</li><li>➤ majority are located within the duodenum</li><li>➤ PPIs are the first-line medical management</li><li>➤ Zollinger–Ellison syndrome (ZES) is a condition that includes:</li><li>➤ Zollinger–Ellison syndrome (ZES) is a condition that includes:</li><li>➤ Fulminating ulcer diathesis in the stomach, duodenum or atypical sites Recurrent ulceration despite ‘adequate’ therapy Non-β islet cell tumours of the pancreas (gastrinoma)</li><li>➤ Fulminating ulcer diathesis in the stomach, duodenum or atypical sites</li><li>➤ Fulminating ulcer diathesis in the stomach, duodenum or atypical sites</li><li>➤ Recurrent ulceration despite ‘adequate’ therapy</li><li>➤ Recurrent ulceration despite ‘adequate’ therapy</li><li>➤ Non-β islet cell tumours of the pancreas (gastrinoma)</li><li>➤ Non-β islet cell tumours of the pancreas (gastrinoma)</li><li>➤ The vast majority (approximately 90%) occur within the ‘gastrinoma triangle’, an area bounded by the junction of the neck and body of the pancreas medially, the junction of the second and third parts of the duodenum inferiorly and the junction of the cystic and common bile ducts superiorly. Within the triangle, duodenum (first part) is the MC site.</li><li>➤ Within the triangle, duodenum (first part) is the MC site.</li><li>➤ Clinical features-</li><li>➤ Clinical features-</li><li>➤ Over 90% of patients with gastrinomas have peptic ulcer disease , often multiple or in unusual sites . Diarrhea is another common symptom, caused by the large volume of gastric acid secretion. Abdominal pain from either peptic ulcer disease or gastro-oesophageal reflux disease remains the most common symptom, occurring in more than 75% of patients. Around 60–95% have a history of high alcohol use, which may be a risk factor.</li><li>➤ Over 90% of patients with gastrinomas have peptic ulcer disease</li><li>➤ multiple or in unusual sites</li><li>➤ Investigations-</li><li>➤ Investigations-</li><li>➤ The cornerstone of diagnosing ZES is an elevated fasting serum gastrin (FSG). If elevated, the gastric pH is measured.</li><li>➤ If the pH is &lt;2 and the FSG is more than 10-fold elevated, the diagnosis is confirmed. If the FSG is less than 10-fold higher, a secretin provocation test should be performed.</li><li>➤ Localisation studies are then indicated as the tumours are often small and multiple. The majority of gastrinomas have a high density of somatotropin receptors. 68Ga-labelled SSAs with PET-CT have been found to be sensitive and specific . If not available, somatostatin scintigraphy (SRS) and EUS should be done.</li><li>➤ 68Ga-labelled SSAs with PET-CT have been found to be sensitive and specific</li><li>➤ Treatment -</li><li>➤ Treatment</li><li>➤ All patients with sporadic gastrinoma without metastases should have a surgical operation by an experienced surgeon. At the time, the peritumoral lymph nodes should be sampled for histological assessment. In MEN 1/gastrinoma, surgery is not recommended for patients with tumours &lt;2 cm. Tumours &gt;2 cm are enucleated. Parathyroidectomy reduces gastric acid secretion. PPI therapy is the management of choice. Even when patients undergo a surgical cure, most (60%) require continued medical treatment.</li><li>➤ All patients with sporadic gastrinoma without metastases should have a surgical operation by an experienced surgeon. At the time, the peritumoral lymph nodes should be sampled for histological assessment.</li><li>➤ All patients with sporadic gastrinoma without metastases should have a surgical operation by an experienced surgeon. At the time, the peritumoral lymph nodes should be sampled for histological assessment.</li><li>➤ In MEN 1/gastrinoma, surgery is not recommended for patients with tumours &lt;2 cm. Tumours &gt;2 cm are enucleated.</li><li>➤ In MEN 1/gastrinoma, surgery is not recommended for patients with tumours &lt;2 cm. Tumours &gt;2 cm are enucleated.</li><li>➤ Parathyroidectomy reduces gastric acid secretion.</li><li>➤ Parathyroidectomy reduces gastric acid secretion.</li><li>➤ PPI therapy is the management of choice. Even when patients undergo a surgical cure, most (60%) require continued medical treatment.</li><li>➤ PPI therapy is the management of choice. Even when patients undergo a surgical cure, most (60%) require continued medical treatment.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 907</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 907</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of these are staging systems used for liver cancer except:", "options": [{"label": "A", "text": "Astler Coller", "correct": true}, {"label": "B", "text": "Barcelona clinic", "correct": false}, {"label": "C", "text": "OKUDA", "correct": false}, {"label": "D", "text": "CLIP", "correct": false}], "correct_answer": "A. Astler Coller", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Astler coller</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Barcelona Clinic. The Barcelona Clinic Liver Cancer (BCLC) staging system is widely used for staging liver cancer , particularly hepatocellular carcinoma (HCC). It incorporates tumor characteristics, liver function, performance status, and cancer-related symptoms.</li><li>• Option B: Barcelona Clinic.</li><li>• Barcelona Clinic Liver Cancer</li><li>• staging system</li><li>• used for staging liver cancer</li><li>• Option C: OKUDA. The Okuda staging system is an older staging system for liver cancer that includes tumor size , serum albumin , bilirubin levels , and the presence of ascites to determine the stage of liver cancer.</li><li>• Option C: OKUDA.</li><li>• older staging system for liver cancer that includes tumor size</li><li>• serum albumin</li><li>• bilirubin levels</li><li>• Option D: CLIP. The Cancer of the Liver Italian Program (CLIP) score is used for prognostic staging of HCC and includes variables such as tumor morphology , AFP levels , Child-Pugh stage , and portal vein thrombosis.</li><li>• Option D: CLIP.</li><li>• Cancer of the Liver Italian Program</li><li>• score</li><li>• prognostic staging of HCC</li><li>• variables such as tumor morphology</li><li>• AFP levels</li><li>• Child-Pugh stage</li><li>• portal vein thrombosis.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Astler-Coller classification is a staging system for colorectal carcinomas , not liver cancer , while the Barcelona clinic , OKUDA , and CLIP are staging systems used for liver cancer , specifically hepatocellular carcinoma.</li><li>➤ Astler-Coller classification</li><li>➤ staging system for colorectal carcinomas</li><li>➤ not liver cancer</li><li>➤ Barcelona clinic</li><li>➤ OKUDA</li><li>➤ CLIP are staging systems used for liver cancer</li><li>➤ Ref: Bailey 28 th Ed. Pg 1407</li><li>➤ Ref: Bailey 28 th Ed. Pg 1407</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is not a component of Kassabach Meritt syndrome?", "options": [{"label": "A", "text": "Thrombocytopenia", "correct": false}, {"label": "B", "text": "Hepatic adenoma", "correct": true}, {"label": "C", "text": "Coagulopathy", "correct": false}, {"label": "D", "text": "Hemolysis", "correct": false}], "correct_answer": "B. Hepatic adenoma", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Hepatic adenoma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Thrombocytopenia. Thrombocytopenia, or low platelet count , is a key feature of KMS and occurs as platelets are consumed within the vascular lesion.</li><li>• Option A: Thrombocytopenia.</li><li>• low platelet count</li><li>• Option C: Coagulopathy. Consumptive coagulopathy , where clotting factors are consumed at a rate faster than they can be produced , is another hallmark of KMS.</li><li>• Option C: Coagulopathy.</li><li>• Consumptive coagulopathy</li><li>• clotting factors are consumed at a rate faster than they can be produced</li><li>• Option D: Hemolysis. Intravascular hemolysis can occur in KMS due to the mechanical destruction of red blood cells as they pass through the vascular tumor.</li><li>• Option D: Hemolysis.</li><li>• Intravascular hemolysis</li><li>• occur in KMS due to the mechanical destruction of red blood cells</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Kasabach-Merritt Syndrome is characterized by the triad of thrombocytopenia, consumptive coagulopathy, and hemolysis , typically associated with vascular lesions such as giant hemangiomas , not hepatic adenomas.</li><li>➤ Kasabach-Merritt Syndrome</li><li>➤ triad of thrombocytopenia, consumptive coagulopathy, and hemolysis</li><li>➤ associated with vascular lesions such as giant hemangiomas</li><li>➤ Hemangioma of liver:</li><li>➤ Hemangioma of liver:</li><li>➤ MC benign liver SOL Asymptomatic/ incidental</li><li>➤ MC benign liver SOL</li><li>➤ Asymptomatic/ incidental</li><li>➤ If &gt; 5cm : May lead to Kassabach Merrit Syndrome</li><li>➤ If &gt; 5cm</li><li>➤ Hemangioma causes hemolysis + Thrombocytopenia + consumptive Coagulopathy.</li><li>➤ CT Abdomen : delayed enhancement</li><li>➤ CT Abdomen</li><li>➤ Treatment :</li><li>➤ Treatment</li><li>➤ Excision if symptomatic</li><li>➤ Excision if symptomatic</li><li>➤ Ref: Bailey 28 th Ed. Pg 1213</li><li>➤ Ref:</li><li>➤ Bailey 28 th Ed. Pg 1213</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Moynihan’s hump is an anatomical variation with respect to which of the below structures?", "options": [{"label": "A", "text": "Left hepatic artery", "correct": false}, {"label": "B", "text": "Cystic artery", "correct": false}, {"label": "C", "text": "Right hepatic artery", "correct": true}, {"label": "D", "text": "Portal vein", "correct": false}], "correct_answer": "C. Right hepatic artery", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture19.jpg"], "explanation": "<p><strong>Ans. C) Right hepatic artery</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• The right hepatic artery (or sometimes the common hepatic artery) can be tortuous (caterpillar turn/ Moynihan’s hump) and may lie very close to the gallbladder and the cystic duct before giving off a short cystic artery .</li><li>• right hepatic artery</li><li>• tortuous</li><li>• may lie very close to the gallbladder</li><li>• cystic duct</li><li>• before giving off a short cystic artery</li><li>• (b) Tortuous Common Hepatic Artery and (c) Tortuous RHA are examples of the ‘caterpillar turn’ or ‘Moynihan’s hump’ , which can lead to inadvertent arterial injury or bleeding during cholecystectomy.</li><li>• Tortuous Common Hepatic Artery</li><li>• Tortuous RHA</li><li>• ‘caterpillar turn’ or ‘Moynihan’s hump’</li><li>• lead to inadvertent arterial injury</li><li>• bleeding during cholecystectomy.</li><li>• Ref: Bailey 28 th Ed. Pg 1233</li><li>• Ref:</li><li>• Bailey 28 th Ed. Pg 1233</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "While performing a cholecystectomy, surgeons ensure that dissection is performed above this particular line, since the cystic artery and cystic duct lie antero-superior to this line and the CBD lies below this line. The line mentioned in this question connects which 2 parts?", "options": [{"label": "A", "text": "Rouviere’s sulcus to segment 5 of liver", "correct": false}, {"label": "B", "text": "Rouviere’s sulcus to segment 4 of liver", "correct": true}, {"label": "C", "text": "Rouviere’s sulcus to Calots triangle", "correct": false}, {"label": "D", "text": "Rouviere’s sulcus to hepatocystic triangle", "correct": false}], "correct_answer": "B. Rouviere’s sulcus to segment 4 of liver", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture20.jpg"], "explanation": "<p><strong>Ans. B) Rouviere’s sulcus to segment 4 of liver</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Rouviere’s sulcus , sometimes referred to as the 'Hjortsjo's Crook, ' is a consistent anatomical landmark identified during gallbladder surgeries such as cholecystectomy.</li><li>• Rouviere’s sulcus</li><li>• 'Hjortsjo's Crook,</li><li>• consistent anatomical landmark</li><li>• gallbladder surgeries such as cholecystectomy.</li><li>• Rouviere’s sulcus on the undersurface of the right lobe of the liver running to the right of the hepatic hilum marks the position of the right posterior sectoral pedicle . The advantage of identifying Rouviere’s sulcus and the line joining the roof of the sulcus to the base of segment IV (R4U line) (Rouviere’s sulcus → segment IV → umbilical fissure) is that the cystic duct and the cystic artery lie ventral (anterosuperior) to the line and the CBD lies below the line. CBD injury can be minimized by maintaining the dissection ventral to the line during cholecystectomy.</li><li>• Rouviere’s sulcus on the undersurface of the right lobe of the liver running to the right of the hepatic hilum marks the position of the right posterior sectoral pedicle .</li><li>• Rouviere’s sulcus on the undersurface of the right lobe of the liver running to the right of the hepatic hilum marks the position of the right posterior sectoral pedicle</li><li>• The advantage of identifying Rouviere’s sulcus and the line joining the roof of the sulcus to the base of segment IV (R4U line) (Rouviere’s sulcus → segment IV → umbilical fissure) is that the cystic duct and the cystic artery lie ventral (anterosuperior) to the line and the CBD lies below the line.</li><li>• CBD injury can be minimized by maintaining the dissection ventral to the line during cholecystectomy.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ When performing a cholecystectomy , it is important to recognize Rouviere's sulcus as it marks the location of the right posterior sectoral pedicle , and dissection above the line connecting Rouviere's sulcus to the base of segment IV helps to avoid injury to the common bile duct (CBD), as the cystic duct and artery lie anterior (ventral) to this line , with the CBD lying below.</li><li>➤ performing a cholecystectomy</li><li>➤ recognize Rouviere's sulcus as it marks the location of the right posterior sectoral pedicle</li><li>➤ dissection above the line connecting Rouviere's sulcus</li><li>➤ base of segment IV</li><li>➤ avoid injury to the common bile duct</li><li>➤ cystic duct and artery lie anterior</li><li>➤ to this line</li><li>➤ Ref: Bailey 28 th Ed. PG 1233</li><li>➤ Ref: Bailey 28 th Ed. PG 1233</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old woman was undergoing a routine check-up when the radiologist noticed gallstones on USG. However, the patient says that there have been no complaints so far and she is asymptomatic. The stone measures 4 cm. What will be your treatment of choice?", "options": [{"label": "A", "text": "Lap cholecystectomy.", "correct": true}, {"label": "B", "text": "Conservative management", "correct": false}, {"label": "C", "text": "Medical dissolution therapy", "correct": false}, {"label": "D", "text": "ERCP and stone removal", "correct": false}], "correct_answer": "A. Lap cholecystectomy.", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Lap cholecystectomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Asymptomatic gallstones do not need intervention however prophylactic cholecystectomy may be performed for asymptomatic cholelithiasis in the following situations:</li><li>• Asymptomatic gallstones</li><li>• do not need intervention</li><li>• prophylactic cholecystectomy</li><li>• asymptomatic cholelithiasis</li><li>• Large (&gt;3 cm) gallstones; Choledocholithiasis; Chronic haemolytic conditions (sickle cell disease, hereditary spherocytosis); Gallbladder polyps &gt;1 cm in diameter; Suspicion/risk of malignancy (anomalous pancreatic ductal drainage); Calcification of the wall (porcelain gallbladder); Some ethnic groups or subjects living in areas with a high prevalence of gallbladder cancer associated with gallstones (some parts of northern India, Native Americans, Mexican Americans, Colombia, Chile, Bolivia); Transplant patients (during transplantation); Bariatric surgery.</li><li>• Large (&gt;3 cm) gallstones;</li><li>• Choledocholithiasis;</li><li>• Chronic haemolytic conditions (sickle cell disease, hereditary spherocytosis);</li><li>• Gallbladder polyps &gt;1 cm in diameter;</li><li>• Suspicion/risk of malignancy (anomalous pancreatic ductal drainage);</li><li>• Calcification of the wall (porcelain gallbladder);</li><li>• Some ethnic groups or subjects living in areas with a high prevalence of gallbladder cancer associated with gallstones (some parts of northern India, Native Americans, Mexican Americans, Colombia, Chile, Bolivia);</li><li>• Transplant patients (during transplantation);</li><li>• Bariatric surgery.</li><li>• ERCP and Stone Removal</li><li>• ERCP and Stone Removal</li><li>• ERCP (Endoscopic Retrograde Cholangiopancreatography) is generally not used for stones in the gallbladder itself but is a treatment option for stones in the common bile duct.</li><li>• ERCP (Endoscopic Retrograde Cholangiopancreatography) is generally not used for stones in the gallbladder itself but is a treatment option for stones in the common bile duct.</li><li>• ERCP</li><li>• not used for stones in the gallbladder</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ For a patient with asymptomatic gallstones measuring 4 cm , the treatment of choice is generally laparoscopic cholecystectomy due to the increased risk of complications associated with larger stones . Medical dissolution therapy is not typically effective for large stones, and ERCP is not indicated unless there is choledocholithiasis (stones in the common bile duct).</li><li>➤ asymptomatic gallstones measuring 4 cm</li><li>➤ laparoscopic cholecystectomy</li><li>➤ increased risk of complications associated with larger stones</li><li>➤ Ref: Bailey 28 th Ed. Pg 1244</li><li>➤ Ref: Bailey 28 th Ed. Pg 1244</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 35-year male with a history of intermittent right upper abdominal pain presents to the clinician. His abdominal examination is normal. An USG abdomen reveals multiple tiny GB calculi. Liver profile shows direct bilirubin of 2.4 mg% and elevated alkaline phosphatase. What is the next step?", "options": [{"label": "A", "text": "ERCP", "correct": false}, {"label": "B", "text": "Antibiotics followed by lap cholecystectomy", "correct": false}, {"label": "C", "text": "HIDA Scan", "correct": false}, {"label": "D", "text": "MRCP", "correct": true}], "correct_answer": "D. MRCP", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) MRCP</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: ERCP (Endoscopic Retrograde Cholangiopancreatography). ERCP is an invasive procedure used to diagnose and treat conditions of the bile ducts , including choledocholithiasis . It is generally performed when there is strong evidence of bile duct stones or when therapeutic intervention is also anticipated.</li><li>• Option A: ERCP (Endoscopic Retrograde Cholangiopancreatography).</li><li>• invasive procedure used to diagnose</li><li>• treat conditions of the bile ducts</li><li>• choledocholithiasis</li><li>• Option B: Antibiotics followed by Laparoscopic Cholecystectomy. This would be the treatment approach if there were signs of infection , such as cholecystitis , and confirmation of gallbladder stones without evidence of CBD stones . However, given the elevated direct bilirubin and alkaline phosphatase, this suggests common bile duct obstruction, likely from stones.</li><li>• Option B: Antibiotics followed by Laparoscopic Cholecystectomy.</li><li>• treatment approach if there were signs of infection</li><li>• cholecystitis</li><li>• confirmation of gallbladder stones without evidence of CBD stones</li><li>• Option C: HIDA Scan (Hepatobiliary Iminodiacetic Acid Scan). A HIDA scan is used to evaluate the function of the gallbladder and bile ducts but is not the best choice when there is already an indication of bile duct obstruction, as it may not provide the necessary detail for stones.</li><li>• Option C: HIDA Scan (Hepatobiliary Iminodiacetic Acid Scan).</li><li>• HIDA scan</li><li>• evaluate the function of the gallbladder and bile ducts</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In a patient with gallbladder calculi and abnormal liver function tests suggestive of biliary obstruction , MRCP is the investigation of choice to evaluate for potential choledocholithiasis and to delineate the biliary anatomy prior to any surgical intervention.</li><li>➤ gallbladder calculi</li><li>➤ abnormal liver function tests</li><li>➤ biliary obstruction</li><li>➤ MRCP is the investigation of choice to evaluate for potential choledocholithiasis</li><li>➤ If there is any concern regarding the diagnosis or the presence of complications such as perforation, CT should also be performed.</li><li>➤ If there is any concern regarding the diagnosis or the presence of complications such as perforation, CT should also be performed.</li><li>➤ If there is any concern regarding the diagnosis or the presence of complications such as perforation, CT should also be performed.</li><li>➤ Ref: Bailey 28 th Ed. Pg 1245</li><li>➤ Ref: Bailey 28 th Ed. Pg 1245</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 60-year-old woman with history of gallstones presents to the casualty with sudden distension of abdomen and signs of dehydration and vomiting. On auscultation, high pitched bowel sounds were noted. Plain abdominal radiograph shows dilated small bowel loops. What is your probable diagnosis?", "options": [{"label": "A", "text": "Mirrizzi syndrome", "correct": false}, {"label": "B", "text": "Biliary pancreatitis", "correct": false}, {"label": "C", "text": "Choledocholithiasis", "correct": false}, {"label": "D", "text": "Gall stone ileus", "correct": true}], "correct_answer": "D. Gall stone ileus", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture23.jpg"], "explanation": "<p><strong>Ans. D) Gallstone ileus</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Mirizzi Syndrome. This condition is characterized by extrinsic compression of the common hepatic duct due to an impacted gallstone in the cystic duct or neck of the gallbladder , leading to jaundice but not typically presenting with small bowel obstruction.</li><li>• Option A: Mirizzi Syndrome.</li><li>• extrinsic compression of the common hepatic duct</li><li>• impacted gallstone in the cystic duct</li><li>• neck of the gallbladder</li><li>• Option B: Biliary pancreatitis. Though this is a likely complication, it would present with acute abdominal pain radiating to back. Paralytic ileus may be seen in severe acute pancreatitis, but it would present with absent bowel sounds.</li><li>• Option B: Biliary pancreatitis.</li><li>• present with acute abdominal pain radiating to back.</li><li>• Option C: Choledocholithiasis. This is the presence of one or more gallstones in the common bile duct , which may lead to biliary colic, jaundice, and pancreatitis , but not small bowel obstruction.</li><li>• Option C: Choledocholithiasis.</li><li>• presence of one or more gallstones</li><li>• common bile duct</li><li>• biliary colic, jaundice, and pancreatitis</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In an elderly female patient with a history of gallstones presenting with abdominal distension, vomiting , and evidence of small bowel obstruction on radiography , gallstone ileus should be highly suspected, especially in the presence of pneumobilia and a calcified gallstone on imaging . Treatment typically involves surgical intervention to relieve the obstruction.</li><li>➤ gallstones presenting with abdominal distension, vomiting</li><li>➤ small bowel obstruction on radiography</li><li>➤ gallstone ileus</li><li>➤ presence of pneumobilia and a calcified gallstone on imaging</li><li>➤ Gallstone ileus is an infrequent complication (0.4%) of cholelithiasis , occurring as a result of impaction of one or more gallstones within the gastrointestinal tract . It is seen more frequently in the elderly and in women. Frequently an episode of acute cholecystitis leads to erosion of inflamed tissues, resulting in a cholecysto-intestinal fistula. A majority of small gallstones pass through the intestines spontaneously. However, gallstones of size 2–5 cm get impacted, usually in the terminal ileum or at the ileocecal valve owing to the relatively narrow lumen and less active peristalsis here. Less common locations include the stomach and the duodenum (Bouveret’s syndrome). Impacted stones may lead to necrosis and perforation followed by peritonitis. Clinical manifestations include acute, intermittent or chronic episodes of partial or complete gastrointestinal obstruction. Physical examination may be non-specific or may show signs of obstruction: dehydration, abdominal distension and tenderness, with high-pitched bowel sounds, and obstructive jaundice. A plain abdominal radiograph shows: Partial or complete intestinal obstruction Pneumobilia or contrast material in the biliary tree An aberrant rim-calcified or total-calcified gallstone A change in the position of such a gallstone on serial films (‘tumbling sign’). CT is considered superior to plain radiographs or USG , with a sensitivity of up to 93%. It additionally shows an abnormal gallbladder with air, an air–fluid level or fluid accumulation with an irregular wall.</li><li>➤ Gallstone ileus is an infrequent complication (0.4%) of cholelithiasis , occurring as a result of impaction of one or more gallstones within the gastrointestinal tract . It is seen more frequently in the elderly and in women.</li><li>➤ Gallstone ileus is an infrequent complication</li><li>➤ cholelithiasis</li><li>➤ impaction of one or more gallstones</li><li>➤ gastrointestinal tract</li><li>➤ Frequently an episode of acute cholecystitis leads to erosion of inflamed tissues, resulting in a cholecysto-intestinal fistula.</li><li>➤ A majority of small gallstones pass through the intestines spontaneously. However, gallstones of size 2–5 cm get impacted, usually in the terminal ileum or at the ileocecal valve owing to the relatively narrow lumen and less active peristalsis here. Less common locations include the stomach and the duodenum (Bouveret’s syndrome). Impacted stones may lead to necrosis and perforation followed by peritonitis.</li><li>➤ Clinical manifestations include acute, intermittent or chronic episodes of partial or complete gastrointestinal obstruction. Physical examination may be non-specific or may show signs of obstruction: dehydration, abdominal distension and tenderness, with high-pitched bowel sounds, and obstructive jaundice. A plain abdominal radiograph shows: Partial or complete intestinal obstruction Pneumobilia or contrast material in the biliary tree An aberrant rim-calcified or total-calcified gallstone A change in the position of such a gallstone on serial films (‘tumbling sign’).</li><li>➤ Partial or complete intestinal obstruction Pneumobilia or contrast material in the biliary tree An aberrant rim-calcified or total-calcified gallstone A change in the position of such a gallstone on serial films (‘tumbling sign’).</li><li>➤ Partial or complete intestinal obstruction</li><li>➤ Pneumobilia or contrast material in the biliary tree</li><li>➤ An aberrant rim-calcified or total-calcified gallstone</li><li>➤ A change in the position of such a gallstone on serial films (‘tumbling sign’).</li><li>➤ CT is considered superior to plain radiographs or USG , with a sensitivity of up to 93%. It additionally shows an abnormal gallbladder with air, an air–fluid level or fluid accumulation with an irregular wall.</li><li>➤ CT is considered superior to plain radiographs or USG</li><li>➤ sensitivity of up to 93%.</li><li>➤ CT abdomen showing Rigler’s triad.</li><li>➤ Ref : Bailey 28 th Ed. Pg 1248</li><li>➤ Ref : Bailey 28 th Ed. Pg 1248</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is an incorrect statement with respect to the risk factors of gall bladder cancers?", "options": [{"label": "A", "text": "Polyps more than 1 cm are considered dangerous", "correct": false}, {"label": "B", "text": "Adenomyomatosis is a common risk factor for carcinoma gallbladder.", "correct": true}, {"label": "C", "text": "Choledochal cysts are pre malignant conditions", "correct": false}, {"label": "D", "text": "Gall stones more than 3 cm pose a risk for cancer", "correct": false}], "correct_answer": "B. Adenomyomatosis is a common risk factor for carcinoma gallbladder.", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Adenomyomatosis is a common risk factor for carcinoma gallbladder.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A: Polyps more than 1cm : Gallbladder polyps larger than 1 cm are considered potential risk factors for gallbladder cancer . Patients with polyps of this size are often recommended to have a cholecystectomy due to the risk of malignancy.</li><li>• Option A:</li><li>• Polyps more than 1cm</li><li>• Gallbladder polyps larger than 1 cm</li><li>• considered potential risk factors for gallbladder cancer</li><li>• Option C: Choledochal cysts are pre-malignant conditions : Choledochal cysts are indeed considered pre-malignant , and there is an association with an increased risk of cholangiocarcinoma as well as Ca gall bladder , a type of cancer that affects the bile ducts.</li><li>• Option C:</li><li>• Choledochal cysts are pre-malignant conditions</li><li>• Choledochal cysts</li><li>• pre-malignant</li><li>• association with an increased risk of cholangiocarcinoma</li><li>• Ca gall bladder</li><li>• Option D: Gallstones more than 3 cm pose a risk for cancer : Large gallstones , especially those greater than 3 cm , are associated with an increased risk of developing gallbladder cancer.</li><li>• Option D:</li><li>• Gallstones more than 3 cm pose a risk for cancer</li><li>• Large gallstones</li><li>• greater than 3 cm</li><li>• increased risk of developing gallbladder cancer.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ Among the listed factors, adenomyomatosis is not commonly a risk factor for gallbladder cancer , whereas gallbladder polyps larger than 1 cm , choledochal cysts , and gallstones larger than 3 cm are recognized risk factors that may warrant surgical intervention for cancer prevention.</li><li>➤ adenomyomatosis</li><li>➤ not commonly a risk factor for gallbladder cancer</li><li>➤ gallbladder polyps larger than 1 cm</li><li>➤ choledochal cysts</li><li>➤ gallstones larger than 3 cm</li><li>➤ Risk factors.</li><li>➤ Gallstones of size more than 3 cm Porcelain gallbladder Anomalous pancreato- biliary junction Choledochal cyst Adenomatous polyps Primary sclerosing cholangitis Obesity Salmonella typhi infection</li><li>➤ Gallstones of size more than 3 cm</li><li>➤ Porcelain gallbladder</li><li>➤ Anomalous pancreato- biliary junction</li><li>➤ Choledochal cyst</li><li>➤ Adenomatous polyps</li><li>➤ Primary sclerosing cholangitis</li><li>➤ Obesity</li><li>➤ Salmonella typhi infection</li><li>➤ GB Polyps : A majority of polyps remain stable . Cholecystectomy should be considered in symptomatic patients or as prophylaxis to prevent malignant transformation in those who also have gallstones, primary sclerosing cholangitis (PSC), biliary colic or pancreatitis.</li><li>➤ GB Polyps</li><li>➤ majority of polyps remain stable</li><li>➤ Polyps in patients older than 50 years, sessile polyps with wall thickening greater than 4 mm and polyps larger than 10 mm merit cholecystectomy. Smaller polyps should be kept under observation.</li><li>➤ Polyps in patients older than 50 years, sessile polyps with wall thickening greater than 4 mm and polyps larger than 10 mm merit cholecystectomy.</li><li>➤ Ref: Bailey 28 th Ed. Pg 1247 and 1258</li><li>➤ Ref: Bailey 28 th Ed. Pg 1247 and 1258</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old patient who is a suffering from gall stones since 2 years, presented with a palpable mass in the right upper quadrant and jaundice. On CECT abdomen, a mass was seen in the gall bladder. Blood marker was positive for CA19-9. Choose the false statement?", "options": [{"label": "A", "text": "Biopsy of the mass is the next step", "correct": true}, {"label": "B", "text": "The most common type is adenocarcinoma", "correct": false}, {"label": "C", "text": "Prophylactic cholecystectomy is done in patients with dangerous polyps", "correct": false}, {"label": "D", "text": "Patients with Ca GB are commonly asymptomatic", "correct": false}], "correct_answer": "A. Biopsy of the mass is the next step", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Biopsy of the mass is the next step.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: The most common type is adenocarcinoma : This is true . The vast majority of gallbladder cancers are adenocarcinomas, which arise from the glandular cells of the gallbladder lining.</li><li>• Option B:</li><li>• The most common type is adenocarcinoma</li><li>• true</li><li>• Option C: Prophylactic cholecystectomy is done in patients with dangerous polyps : This is</li><li>• Option C:</li><li>• Prophylactic cholecystectomy is done in patients with dangerous polyps</li><li>• true . Prophylactic cholecystectomy is recommended for gallbladder polyps that are larger than 1 cm, especially if they are symptomatic or if the patient has other risk factors for gallbladder cancer, such as being over 50 years old or having concurrent gallstones.</li><li>• true</li><li>• Option D: Patients with Ca GB are commonly asymptomatic : This is generally true . Many patients with gallbladder cancer are asymptomatic or present with non-specific symptoms similar to those of benign gallbladder disease, making early diagnosis difficult.</li><li>• Option D:</li><li>• Patients with Ca GB are commonly asymptomatic</li><li>• true</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ For suspected gallbladder cancer , a biopsy is generally not the first step due to potential risks . Instead, imaging studies are utilized for diagnosis , with a CECT abdomen for local staging and a PET CT for detecting distant metastases. Gallbladder cancer is most commonly an adenocarcinoma , and prophylactic cholecystectomy is recommended for polyps greater than 1 cm to prevent malignant transformation . Patients often present late in the course of the disease due to nonspecific symptoms or asymptomatic progression.</li><li>➤ suspected gallbladder cancer</li><li>➤ biopsy is generally not the first step due to potential risks</li><li>➤ imaging studies are utilized for diagnosis</li><li>➤ CECT abdomen for local staging</li><li>➤ PET CT for detecting distant metastases.</li><li>➤ Gallbladder cancer</li><li>➤ commonly an adenocarcinoma</li><li>➤ prophylactic cholecystectomy</li><li>➤ polyps greater than 1 cm</li><li>➤ prevent malignant transformation</li><li>➤ Dangerous polyps are polyps more than 1cm, in a patient more than 50 years and associated with gall stones. Prophylactic cholecystectomy is done in such cases. GB cancer patients are most commonly asymptomatic and present late. Tumour markers: CA 19-9 and CEA Symptoms, if present, are usually indistinguishable from those of benign gallbladder disease such as biliary colic or cholecystitis, particularly in older patients. Jaundice and anorexia are late features, heralding a low resectability rate and even fewer negative margins. A palpable mass is a late sign.</li><li>➤ Dangerous polyps are polyps more than 1cm, in a patient more than 50 years and associated with gall stones. Prophylactic cholecystectomy is done in such cases.</li><li>➤ Dangerous polyps are polyps more than 1cm, in a patient more than 50 years and associated with gall stones. Prophylactic cholecystectomy is done in such cases.</li><li>➤ GB cancer patients are most commonly asymptomatic and present late.</li><li>➤ GB cancer patients are most commonly asymptomatic and present late.</li><li>➤ Tumour markers: CA 19-9 and CEA</li><li>➤ Tumour markers: CA 19-9 and CEA</li><li>➤ Symptoms, if present, are usually indistinguishable from those of benign gallbladder disease such as biliary colic or cholecystitis, particularly in older patients. Jaundice and anorexia are late features, heralding a low resectability rate and even fewer negative margins. A palpable mass is a late sign.</li><li>➤ Symptoms, if present, are usually indistinguishable from those of benign gallbladder disease such as biliary colic or cholecystitis, particularly in older patients. Jaundice and anorexia are late features, heralding a low resectability rate and even fewer negative margins. A palpable mass is a late sign.</li><li>➤ Ref: Bailey 28 th Ed. Page 1258</li><li>➤ Ref: Bailey 28 th Ed. Page 1258</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient underwent laparoscopic cholecystectomy for cholelithiasis. Histopathology of the resected gall bladder is reported as Stage T1a of gallbladder cancer. What would be the next line of management?", "options": [{"label": "A", "text": "No further treatment", "correct": true}, {"label": "B", "text": "Perform extended cholecystectomy", "correct": false}, {"label": "C", "text": "Adjuvant chemotherapy", "correct": false}, {"label": "D", "text": "Radiation", "correct": false}], "correct_answer": "A. No further treatment", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) No further treatment.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Perform extended cholecystectomy : Extended cholecystectomy is typically reserved for T1b lesions or higher .</li><li>• Option B:</li><li>• Perform extended cholecystectomy</li><li>• reserved for T1b lesions or higher</li><li>• Option C: Adjuvant chemotherapy : There is no role for adjuvant chemotherapy in T1a gallbladder cancer after complete resection, given the low risk of recurrence.</li><li>• Option C:</li><li>• Adjuvant chemotherapy</li><li>• no role for adjuvant chemotherapy</li><li>• T1a gallbladder cancer</li><li>• Option D: Radiation : Radiation is not part of the standard management for T1a gallbladder cancer following a cholecystectomy with negative margins.</li><li>• Option D:</li><li>• Radiation</li><li>• not part of the standard management for T1a gallbladder cancer</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ For stage T1a gallbladder cancer , where the tumor is confined to the lamina propria and does not invade the muscle layer , simple cholecystectomy with clear margins is considered definitive treatment , with no further therapy required. Extended cholecystectomy, chemotherapy , and radiation are not indicated unless there are features suggestive of more advanced disease.</li><li>➤ stage T1a gallbladder cancer</li><li>➤ tumor is confined to the lamina propria</li><li>➤ not invade the muscle layer</li><li>➤ simple cholecystectomy</li><li>➤ clear margins</li><li>➤ definitive treatment</li><li>➤ Extended cholecystectomy, chemotherapy</li><li>➤ Treatment options for carcinoma gall bladder found incidentally after cholecystectomy:</li><li>➤ Treatment options for carcinoma gall bladder found incidentally after cholecystectomy:</li><li>➤ T1a with negative margins: Standard cholecystectomy T1a with perineural/ lymphatic/ vascular invasion: Extended cholecystectomy Chemotherapy is not required in an early gall bladder cancer. Radiation has no role. T1b: Extended cholecystectomy. No need for port site excision.</li><li>➤ T1a with negative margins: Standard cholecystectomy</li><li>➤ T1a with negative margins: Standard cholecystectomy</li><li>➤ T1a with perineural/ lymphatic/ vascular invasion: Extended cholecystectomy Chemotherapy is not required in an early gall bladder cancer. Radiation has no role.</li><li>➤ T1a with perineural/ lymphatic/ vascular invasion: Extended cholecystectomy Chemotherapy is not required in an early gall bladder cancer. Radiation has no role.</li><li>➤ T1b: Extended cholecystectomy. No need for port site excision.</li><li>➤ T1b: Extended cholecystectomy. No need for port site excision.</li><li>➤ T1b: Extended cholecystectomy. No need for port site excision.</li><li>➤ Treatment of gallbladder carcinoma (in general):</li><li>➤ T1a: Simple cholecystectomy T1b, T2, T3: Radical cholecystectomy T4: Unresectable, chemotherapy and palliative nonsurgical therapy are provided.</li><li>➤ T1a: Simple cholecystectomy</li><li>➤ T1a: Simple cholecystectomy</li><li>➤ T1b, T2, T3: Radical cholecystectomy</li><li>➤ T1b, T2, T3: Radical cholecystectomy</li><li>➤ T4: Unresectable, chemotherapy and palliative nonsurgical therapy are provided.</li><li>➤ T4: Unresectable, chemotherapy and palliative nonsurgical therapy are provided.</li><li>➤ Note: Port-site excision is no longer performed for the management of gallbladder carcinoma.</li><li>➤ Note: Port-site excision is no longer performed for the management of gallbladder carcinoma.</li><li>➤ TNM STAGING</li><li>➤ TNM STAGING</li><li>➤ T: depth of invasion</li><li>➤ T1a: mucosa</li><li>➤ T1b: muscularis</li><li>➤ T2: subserosal connective tissue</li><li>➤ T3: resectable surrounding adjacent structure (LIVER OR DUODENUM) / breach of serosa</li><li>➤ T4: unresectable surrounding structures involved like portal vein, hepatic artery</li><li>➤ N1: 1-3 regional nodes</li><li>➤ N2: &gt; 4 regional nodes</li><li>➤ Ref : Bailey 28 th Ed. Pg 1258-59</li><li>➤ Ref : Bailey 28 th Ed. Pg 1258-59</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Rigler’s triad includes all except:", "options": [{"label": "A", "text": "Small bowel obstruction", "correct": false}, {"label": "B", "text": "Pneumobilia", "correct": false}, {"label": "C", "text": "Calcified gallstones in region of small bowel", "correct": false}, {"label": "D", "text": "Positive Murphy’s sign", "correct": true}], "correct_answer": "D. Positive Murphy’s sign", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture24.jpg"], "explanation": "<p><strong>Ans. D. Positive Murphy’s sign</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Small bowel obstruction - This is a component of Rigler's triad , which is indicative of gallstone ileus , a condition where a gallstone causes an obstruction in the small bowel .</li><li>• Option A: Small bowel obstruction</li><li>• component of Rigler's triad</li><li>• indicative of gallstone ileus</li><li>• gallstone causes an obstruction in the small bowel</li><li>• Option B: Pneumobilia - Air in the biliary tree is another component of Rigler's triad and is a classic finding in gallstone ileus, typically resulting from a cholecystoenteric fistula.</li><li>• Option B:</li><li>• Pneumobilia</li><li>• Air in the biliary tree</li><li>• component of Rigler's triad</li><li>• Option C: Calcified gallstones in the region of small bowel - This is the third component of Rigler's triad . It indicates the presence of a gallstone that has likely migrated from the gallbladder into the intestinal tract, causing obstruction.</li><li>• Option C:</li><li>• Calcified gallstones in the region of small bowel</li><li>• third component of Rigler's triad</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ Rigler's triad , which consists of small bowel obstruction, pneumobilia, and calcified gallstones in the region of the small bowel , is a radiological finding indicative of gallstone ileus .</li><li>➤ Rigler's triad</li><li>➤ small bowel obstruction, pneumobilia, and calcified gallstones in the region of the small bowel</li><li>➤ radiological finding indicative of gallstone ileus</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "What will be the treatment of choice in a choledochal cyst that has been classified by Todani as grade III?", "options": [{"label": "A", "text": "Excision + hepaticojejunal anastomosis", "correct": false}, {"label": "B", "text": "Only excision", "correct": false}, {"label": "C", "text": "Endoscopic sphincterotomy", "correct": true}, {"label": "D", "text": "Excision + liver transplantation", "correct": false}], "correct_answer": "C. Endoscopic sphincterotomy", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture26.jpg"], "explanation": "<p><strong>Ans. C. Endoscopy sphincterotomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Excision + hepaticojejunal anastomosis . This is generally the treatment for Type I choledochal cysts , which involve fusiform dilation of the common bile duct.</li><li>• Option A:</li><li>• Excision + hepaticojejunal anastomosis</li><li>• treatment for Type I choledochal cysts</li><li>• Option B: Only excision . Excision alone may be suitable for Type II choledochal cysts , which are typically diverticulum-like outpouchings of the bile duct.</li><li>• Option B:</li><li>• Only excision</li><li>• suitable for Type II choledochal cysts</li><li>• Option D: Excision + liver transplantation . This approach is reserved for Type IV cysts with extensive intrahepatic involvement and for cases with significant liver damage or cirrhosis.</li><li>• Option D:</li><li>• Excision + liver transplantation</li><li>• reserved for Type IV cysts</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ The management of choledochal cysts varies depending on the Todani classification of the cyst . For a Type III choledochal cyst , endoscopic sphincterotomy is the treatment of choice , aimed at relieving the obstruction at the level of the ampulla of Vater . It is essential for clinicians to correctly classify the type of choledochal cyst to determine the appropriate surgical intervention.</li><li>➤ management of choledochal cysts varies depending on the Todani classification of the cyst</li><li>➤ Type III choledochal cyst</li><li>➤ endoscopic sphincterotomy</li><li>➤ treatment of choice</li><li>➤ relieving the obstruction at the level of the ampulla of Vater</li><li>➤ Treatment depends on classification.</li><li>➤ Treatment depends on classification.</li><li>➤ Type I - Saccular/Fusiform: excision and reconstruction by hepaticojejunal anastomosis</li><li>➤ Type I</li><li>➤ Type II -Diverticulum: excision</li><li>➤ Type II</li><li>➤ Type III - Intraduodenal/choledochocele: ERCP + sphincterotomy + cyst deroofing</li><li>➤ Type III</li><li>➤ Type IV A - diffuse intrahepatic + Extrahepatic: Resection + Liver transplantation</li><li>➤ Type IV A</li><li>➤ Type IV B - Diffuse extrahepatic: Resection + Reconstruction/Liver transplant</li><li>➤ Type IV B</li><li>➤ Type V - diffuse intrahepatic/Caroli’s disease: resection + liver transplantation</li><li>➤ Type V</li><li>➤ Ref: Bailey 28 th Ed. Pg. 1242</li><li>➤ Ref:</li><li>➤ Bailey 28 th Ed. Pg. 1242</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is NOT an exception to Courvoisier’s law?", "options": [{"label": "A", "text": "Double impaction stone", "correct": false}, {"label": "B", "text": "Klatskin's tumor", "correct": false}, {"label": "C", "text": "Periampullary cancer", "correct": true}, {"label": "D", "text": "Early slippage of stone", "correct": false}], "correct_answer": "C. Periampullary cancer", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Periampullary cancer</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Double impaction stone - This is an exception to Courvoisier's law because the gallbladder may become palpable due to the obstruction caused by two stones , one in the cystic duct and one in the common bile duct.</li><li>• Option A:</li><li>• Double impaction stone</li><li>• exception to Courvoisier's law</li><li>• gallbladder may become palpable</li><li>• obstruction caused by two stones</li><li>• Option B: Klatskin's tumor - This refers to a tumor at the confluence of the right and left hepatic bile ducts , and it is an exception to Courvoisier’s law because it can cause bile duct obstruction without gall bladder enlargement, as bile as obstructed proximal to cystic duct.</li><li>• Option B:</li><li>• Klatskin's tumor</li><li>• tumor at the confluence of the right and left hepatic bile ducts</li><li>• exception to Courvoisier’s law</li><li>• Option D: Early slippage of stone - This is an exception to Courvoisier’s law, as the gallbladder can be palpable in the case of an early slippage of a stone before chronic inflammation sets in , which would otherwise lead to a shrunken, fibrotic gallbladder.</li><li>• Option D:</li><li>• Early slippage of stone</li><li>• gallbladder can be palpable in the case of an early slippage of a stone</li><li>• chronic inflammation sets in</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ Courvoisier's law suggests that in the presence of obstructive jaundice , a palpable gallbladder is more likely due to a cause other than gallstones , such as a periampullary or pancreatic head tumor . Exceptions include conditions where the gallbladder distension occurs without prior cholecystitis, such as with double impaction stones, early slippage of a stone, Mirizzi syndrome, and Klatskin’s tumor.</li><li>➤ Courvoisier's law</li><li>➤ presence of obstructive jaundice</li><li>➤ palpable gallbladder is more likely due to a cause other than gallstones</li><li>➤ periampullary or pancreatic head tumor</li><li>➤ According to the law, if GB is palpable in obstructive jaundice- etiology is Periampullary mass. In patients of CBD stones, GB is seldom palpable due to earlier attacks of cholecystitis. Exceptions : Double impacted stone, Early slipped stone, Mirizzi syndrome, Klatskin’s tumor.</li><li>➤ According to the law, if GB is palpable in obstructive jaundice- etiology is Periampullary mass. In patients of CBD stones, GB is seldom palpable due to earlier attacks of cholecystitis.</li><li>➤ Exceptions : Double impacted stone, Early slipped stone, Mirizzi syndrome, Klatskin’s tumor.</li><li>➤ Exceptions</li><li>➤ Ref: Bailey 28 th Ed. Pg 1283</li><li>➤ Ref:</li><li>➤ Bailey 28 th Ed. Pg 1283</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the incorrect statement with respect to the device shown below?", "options": [{"label": "A", "text": "One limb is placed is common bile duct", "correct": false}, {"label": "B", "text": "Used for transhepatic drainage of bile", "correct": true}, {"label": "C", "text": "Burhenne’s technique is used for removal of residual stones", "correct": false}, {"label": "D", "text": "Cholangiogram is performed after bile becomes clear and patient is clinically improved", "correct": false}], "correct_answer": "B. Used for transhepatic drainage of bile", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture30.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture31.jpg"], "explanation": "<p><strong>Ans. B. Used for transhepatic drainage of bile.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A: Correct . The T-tube is designed with one limb to be placed in the common bile duct during surgery to ensure bile drainage and to prevent accumulation in the site of surgery.</li><li>• Option A: Correct</li><li>• Option C: Correct . Burhenne’s technique may involve the use of a mature T-tube tract for the removal of residual stones in the bile duct.</li><li>• Option C: Correct</li><li>• Option D: Correct . After placement of a T-tube, a cholangiogram can be performed to assess the bile ducts once the patient has clinically improved and the bile drainage is clear, indicating no further obstruction or leak.</li><li>• Option D: Correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ When managing a patient after CBD exploration , a T-tube may be placed for bile drainage . The T-tube is not used for transhepatic drainage but rather for post-surgical drainage and access for potential removal of residual stones . A cholangiogram is performed after recovery to ensure clear drainage before the tube is removed.</li><li>➤ CBD exploration</li><li>➤ T-tube may be placed for bile drainage</li><li>➤ T-tube is not used for transhepatic drainage</li><li>➤ post-surgical drainage</li><li>➤ access for potential removal of residual stones</li><li>➤ When faced with a patient with cholangitis due to stones in the CBD, and minimally invasive techniques for stone extraction are not possible, the surgeon must undertake laparotomy, drain the CBD and remove the stones through a longitudinal incision in the duct. A T-tube is inserted and the duct closed around it; the long limb is brought out on the right side and bile is allowed to drain externally. When the bile becomes clear and the patient has recovered, a cholangiogram is performed. If residual stones are found, the tube is left in place for 6 weeks so that the track is ‘mature’. The radiologist can then use the track for percutaneous removal of the stones (Burhenne’s). Once the radiologist has removed the tube, the track will close and the patient will recover. Such residual small stones are now usually managed with endoscopic methods.</li><li>➤ When faced with a patient with cholangitis due to stones in the CBD, and minimally invasive techniques for stone extraction are not possible, the surgeon must undertake laparotomy, drain the CBD and remove the stones through a longitudinal incision in the duct.</li><li>➤ A T-tube is inserted and the duct closed around it; the long limb is brought out on the right side and bile is allowed to drain externally. When the bile becomes clear and the patient has recovered, a cholangiogram is performed.</li><li>➤ If residual stones are found, the tube is left in place for 6 weeks so that the track is ‘mature’. The radiologist can then use the track for percutaneous removal of the stones (Burhenne’s). Once the radiologist has removed the tube, the track will close and the patient will recover. Such residual small stones are now usually managed with endoscopic methods.</li><li>➤ Ref : Bailey 28 th Ed. Pg 1254</li><li>➤ Ref : Bailey 28 th Ed. Pg 1254</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Ascending cholangitis, often associated with CBD stones, is a life-threatening condition that may present with the Reynaud’s pentad. Which of the following is NOT a part of the above-mentioned pentad?", "options": [{"label": "A", "text": "RUQ pain", "correct": false}, {"label": "B", "text": "Jaundice", "correct": false}, {"label": "C", "text": "Hypertension", "correct": true}, {"label": "D", "text": "Altered mental state", "correct": false}], "correct_answer": "C. Hypertension", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture32.jpg"], "explanation": "<p><strong>Ans. C) Hypertension</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: RUQ pain is a classic symptom that is part of Charcot's triad and Reynaud’s pentad for ascending cholangitis , reflecting inflammation in the right upper quadrant of the abdomen.</li><li>• Option A:</li><li>• RUQ pain</li><li>• classic symptom</li><li>• Charcot's triad</li><li>• Reynaud’s pentad for ascending cholangitis</li><li>• Option B: Jaundice is also a part of Charcot's triad and Reynaud’s pentad , typically resulting from bile duct obstruction leading to elevated direct bilirubin levels.</li><li>• Option B:</li><li>• Jaundice</li><li>• Charcot's triad and Reynaud’s pentad</li><li>• Option D: Altered mental state (lethargy or confusion) is part of Reynaud’s pentad , which suggests a progression to systemic illness and septicemia .</li><li>• Option D:</li><li>• Altered mental state</li><li>• Reynaud’s pentad</li><li>• progression to systemic illness and septicemia</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Reynaud’s pentad for ascending cholangitis includes right upper quadrant pain, jaundice, fever with chills (rigors), altered mental state , and hypotension , not hypertension , indicating a potential progression to septic shock . Recognizing these signs is crucial as ascending cholangitis is a life-threatening condition that requires prompt medical intervention.</li><li>➤ Reynaud’s pentad</li><li>➤ ascending cholangitis</li><li>➤ right upper quadrant pain, jaundice, fever with chills</li><li>➤ altered mental state</li><li>➤ hypotension</li><li>➤ not hypertension</li><li>➤ potential progression to septic shock</li><li>➤ Ascending cholangitis is a potentially life-threatening emergency associated with infection of the biliary tree and usually associated with obstruction. It presents with clinical jaundice, rigors and a tender right upper quadrant (Charcot’s triad).</li><li>➤ Ascending cholangitis is a potentially life-threatening emergency associated with infection of the biliary tree and usually associated with obstruction. It presents with clinical jaundice, rigors and a tender right upper quadrant (Charcot’s triad).</li><li>➤ Ref : Bailey 28 th Ed. Pg. 1208</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg. 1208</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old patient presents with abdominal pain, jaundice and weight loss. MRCP revealed a tumor involving the biliary confluence with unilateral extension to second-order biliary radicles. What is the staging of this tumor according to Bismuth-Corlette?", "options": [{"label": "A", "text": "I", "correct": false}, {"label": "B", "text": "II", "correct": false}, {"label": "C", "text": "III", "correct": true}, {"label": "D", "text": "IV", "correct": false}], "correct_answer": "C. III", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture33.jpg"], "explanation": "<p><strong>Ans. C) III</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• The anatomical extent of the disease is classified according to either the Bismuth–Corlette or the Memorial Sloan Kettering Cancer Center (MSKCC) classification.</li><li>• anatomical extent of the disease</li><li>• Bismuth–Corlette</li><li>• Memorial Sloan Kettering Cancer Center</li><li>• Staging of Klastkin tumour - Bismuth Corlette tumour types (image)</li><li>• Staging of Klastkin tumour - Bismuth Corlette tumour types</li><li>• I - away from confluence &gt; 1cm</li><li>• I</li><li>• II - near confluence &lt;1cm</li><li>• II</li><li>• III - tumour infiltrating one of the branches of CHD (left or right)</li><li>• III</li><li>• IV - infiltrates both the branches (left and right)</li><li>• IV</li><li>• Bismuth-Corlette type of cholangiocarcinoma</li><li>• Bismuth-Corlette type of cholangiocarcinoma</li><li>• The MSKCC classification T-stage criteria for hilar cholangiocarcinoma are as follows :</li><li>• MSKCC classification T-stage criteria for hilar cholangiocarcinoma are as follows</li><li>• T1 tumour involving the biliary confluence without extension to second-order biliary radicles. T2 tumour involving the biliary confluence with unilateral extension to second-order biliary radicles and ipsilateral portal vein involvement or ipsilateral hepatic atrophy. T3 tumour involving the biliary confluence with bilateral extension to second-order biliary radicles; or unilateral extension to second-order biliary radicles with contra- lateral portal vein involvement; or unilateral extension to second-order biliary radicles with contralateral hepatic lobar atrophy; or main or bilateral portal venous involvement.</li><li>• T1 tumour involving the biliary confluence without extension to second-order biliary radicles.</li><li>• T1 tumour</li><li>• biliary confluence</li><li>• without extension</li><li>• T2 tumour involving the biliary confluence with unilateral extension to second-order biliary radicles and ipsilateral portal vein involvement or ipsilateral hepatic atrophy.</li><li>• T2 tumour</li><li>• biliary confluence</li><li>• unilateral extension</li><li>• T3 tumour involving the biliary confluence with bilateral extension to second-order biliary radicles; or unilateral extension to second-order biliary radicles with contra- lateral portal vein involvement; or unilateral extension to second-order biliary radicles with contralateral hepatic lobar atrophy; or main or bilateral portal venous involvement.</li><li>• T3 tumour</li><li>• biliary confluence</li><li>• bilateral extension</li><li>• Ref: Bailey 28 th Ed. Pg 1257</li><li>• Ref:</li><li>• Bailey 28 th Ed. Pg 1257</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the incorrect statement with respect to cholangiocarcinoma:", "options": [{"label": "A", "text": "The tumour marker is CA 19-9", "correct": false}, {"label": "B", "text": "Tumors of T1 staging are treated with percutaneous transhepatic biliary drain", "correct": true}, {"label": "C", "text": "Most of the patients are unresectable at presentation", "correct": false}, {"label": "D", "text": "Investigation of choice is MRCP with MRI liver", "correct": false}], "correct_answer": "B. Tumors of T1 staging are treated with percutaneous transhepatic biliary drain", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Tumors of T1 staging are treated with percutaneous transhepatic biliary drain</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: The tumor marker for cholangiocarcinoma is CA 19-9 . CA 19-9 can be elevated in patients with this cancer and is used for diagnosis and monitoring.</li><li>• Option A:</li><li>• tumor marker for cholangiocarcinoma is CA 19-9</li><li>• Option C: Most patients with cholangiocarcinoma are indeed unresectable at the time of presentation . Surgical resection is often possible only in a minority of cases, and the majority of patients are diagnosed at an advanced stage.</li><li>• Option C:</li><li>• cholangiocarcinoma are indeed unresectable at the time of presentation</li><li>• Option D: The investigation of choice for evaluating cholangiocarcinoma is MRCP (Magnetic Resonance Cholangiopancreatography) with MRI of the liver . This imaging modality provides detailed visualization of the bile ducts and liver and helps in diagnosing and staging the cancer.</li><li>• Option D:</li><li>• evaluating cholangiocarcinoma is MRCP</li><li>• with MRI of the liver</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Cholangiocarcinoma is often diagnosed at an advanced stage , making surgical resection suitable for only a minority of patients . The tumor marker CA 19-9 is used for diagnosis and monitoring . MRCP with MRI of the liver is the preferred imaging method for evaluating cholangiocarcinoma. PTBD is more commonly used for palliative relief of biliary obstruction in unresectable cases.</li><li>➤ Cholangiocarcinoma</li><li>➤ diagnosed at an advanced stage</li><li>➤ surgical resection suitable for only a minority of patients</li><li>➤ tumor marker CA 19-9</li><li>➤ diagnosis and monitoring</li><li>➤ MRCP with MRI of the liver is the preferred imaging method</li><li>➤ The majority of patients present with advanced disease. However, 10–15% patients are suitable for surgical resection, which offers the only hope for long-term survival. Operable tumors such as T1 staged tumors are treated with resection. Depending on the site of disease, surgery involves either a standard or extended hepatic resection with caudate lobe excision with en bloc lymphadenectomy and reconstruction of the biliary tree. Distal common duct tumors may require pancreaticoduodenectomy (Whipple procedure). Local resection should be avoided. The majority of patients who present with unresectable disease are candidates for palliative chemotherapy – gemcitabine with cisplatin. The aim is to maintain or improve quality of life by relieving symptoms and preventing cholestatic liver failure. Biliary obstruction can be relieved by endoscopic (ERCP) or percutaneous (PTC) methods.</li><li>➤ The majority of patients present with advanced disease. However, 10–15% patients are suitable for surgical resection, which offers the only hope for long-term survival.</li><li>➤ Operable tumors such as T1 staged tumors are treated with resection. Depending on the site of disease, surgery involves either a standard or extended hepatic resection with caudate lobe excision with en bloc lymphadenectomy and reconstruction of the biliary tree. Distal common duct tumors may require pancreaticoduodenectomy (Whipple procedure). Local resection should be avoided.</li><li>➤ Operable tumors such as T1 staged tumors are treated with resection.</li><li>➤ The majority of patients who present with unresectable disease are candidates for palliative chemotherapy – gemcitabine with cisplatin. The aim is to maintain or improve quality of life by relieving symptoms and preventing cholestatic liver failure. Biliary obstruction can be relieved by endoscopic (ERCP) or percutaneous (PTC) methods.</li><li>➤ Ref: Bailey 28 th Ed. Pg. 1257-58</li><li>➤ Ref: Bailey 28 th Ed. Pg. 1257-58</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following blood vessels is not related to the pancreas?", "options": [{"label": "A", "text": "Celiac trunk", "correct": true}, {"label": "B", "text": "Superior mesenteric artery", "correct": false}, {"label": "C", "text": "Superior mesenteric vein", "correct": false}, {"label": "D", "text": "Splenic artery", "correct": false}], "correct_answer": "A. Celiac trunk", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture34.jpg"], "explanation": "<p><strong>Ans. A) Celiac trunk</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: The superior mesenteric artery (SMA) is related to the pancreas . It is a major branch of the abdominal aorta and supplies blood to the midgut , including parts of the small intestine, cecum, and ascending colon. The SMA runs posterior to the neck of the pancreas.</li><li>• Option B:</li><li>• superior mesenteric artery</li><li>• related to the pancreas</li><li>• major branch of the abdominal aorta</li><li>• blood to the midgut</li><li>• Option C: The superior mesenteric vein (SMV) is related to the pancreas. It drains blood from the midgut and forms an important venous structure in the abdomen . The SMV joins with the splenic vein behind the neck of the pancreas to form the portal vein.</li><li>• Option C:</li><li>• superior mesenteric vein</li><li>• related to the pancreas.</li><li>• drains blood from the midgut</li><li>• important venous structure in the abdomen</li><li>• Option D: The splenic artery is related to the pancreas . It is a branch of the celiac trunk and supplies blood to the spleen , but it also gives off branches that run along the superior border of the pancreas, contributing to the pancreatic blood supply.</li><li>• Option D:</li><li>• splenic artery</li><li>• pancreas</li><li>• branch of the celiac trunk</li><li>• supplies blood to the spleen</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The celiac trunk is not directly related to the pancreas , while the superior mesenteric artery, superior mesenteric vein , and splenic artery have anatomical relationships with the pancreas and are involved in its blood supply . Understanding these anatomical relationships is essential for surgical and diagnostic purposes.</li><li>➤ celiac trunk is not directly related to the pancreas</li><li>➤ superior mesenteric artery, superior mesenteric vein</li><li>➤ splenic artery</li><li>➤ relationships with the pancreas</li><li>➤ involved in its blood supply</li><li>➤ Important points on anatomy of pancreas-</li><li>➤ Important points on anatomy of pancreas-</li><li>➤ The pancreas is situated in the retroperitoneum. It is divided into a head, which occupies 30% of the gland by mass, and a body and tail, which together constitute 70%. The head lies within the curve of the duodenum, overlying the body of the second lumbar vertebra and the vena cava. The abdominal aorta and the superior mesenteric vessels lie behind the neck of the gland. Coming of the side of the pancreatic head and passing to the left and behind the superior mesenteric vein is the uncinate process of the pancreas. Behind the neck of the pancreas, near its upper border, the superior mesenteric vein joins the splenic vein to form the portal vein. The tip of the pancreatic tail extends up to the splenic hilum.</li><li>➤ The pancreas is situated in the retroperitoneum. It is divided into a head, which occupies 30% of the gland by mass, and a body and tail, which together constitute 70%.</li><li>➤ The head lies within the curve of the duodenum, overlying the body of the second lumbar vertebra and the vena cava.</li><li>➤ The abdominal aorta and the superior mesenteric vessels lie behind the neck of the gland.</li><li>➤ Coming of the side of the pancreatic head and passing to the left and behind the superior mesenteric vein is the uncinate process of the pancreas.</li><li>➤ Behind the neck of the pancreas, near its upper border, the superior mesenteric vein joins the splenic vein to form the portal vein.</li><li>➤ The tip of the pancreatic tail extends up to the splenic hilum.</li><li>➤ Ref : Bailey and Love 28 th Edition Page 1260</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th Edition Page 1260</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A neonate with Down’s syndrome was brought with multiple episodes of vomiting since birth. Duodenal obstruction due to annular pancreas was diagnosed. What is the definitive treatment of this condition?", "options": [{"label": "A", "text": "Percutaneous gastrostomy", "correct": false}, {"label": "B", "text": "Duodeno-duodenostomy", "correct": true}, {"label": "C", "text": "Duodenojejunostomy", "correct": false}, {"label": "D", "text": "Gastrojejunostomy", "correct": false}], "correct_answer": "B. Duodeno-duodenostomy", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture36.jpg"], "explanation": "<p><strong>Ans. B) Duodenoduodenostomy.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Percutaneous gastrostomy is not the definitive treatment for annular pancreas . It involves the placement of a feeding tube into the stomach and is used for nutritional support but does not address the duodenal obstruction caused by annular pancreas.</li><li>• Option A:</li><li>• Percutaneous gastrostomy</li><li>• not the definitive treatment for annular pancreas</li><li>• Option C: Duodenojejunostomy involves creating an opening between the duodenum and the jejunum and is not the preferred surgical procedure for annular pancreas.</li><li>• Option C:</li><li>• Duodenojejunostomy</li><li>• creating an opening between the duodenum and the jejunum</li><li>• Option D: Gastrojejunostomy involves creating an opening between the stomach and the jejunum and is not the appropriate treatment for duodenal obstruction due to annular pancreas.</li><li>• Option D:</li><li>• Gastrojejunostomy</li><li>• creating an opening between the stomach</li><li>• jejunum</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In neonates with Down's syndrome presenting with duodenal obstruction due to annular pancreas , the definitive treatment is duodenoduodenostomy.</li><li>➤ neonates with Down's syndrome</li><li>➤ duodenal obstruction</li><li>➤ annular pancreas</li><li>➤ duodenoduodenostomy.</li><li>➤ Annular pancreas : This is the result of failure of complete rotation of the ventral pancreatic bud during development, so that a ring of pancreatic tissue surrounds the second or third part of the duodenum.</li><li>➤ Annular pancreas</li><li>➤ It is most often seen in association with congenital duodenal stenosis or atresia and is therefore more prevalent in children with Down syndrome. Duodenal obstruction typically causes vomiting in the neonate. The usual treatment is bypass (duodenoduodenostomy). The diagnosis may be made in later life as a cause of pancreatitis, in which case resection of the head of the pancreas should be considered.</li><li>➤ It is most often seen in association with congenital duodenal stenosis or atresia and is therefore more prevalent in children with Down syndrome.</li><li>➤ Duodenal obstruction typically causes vomiting in the neonate.</li><li>➤ The usual treatment is bypass (duodenoduodenostomy). The diagnosis may be made in later life as a cause of pancreatitis, in which case resection of the head of the pancreas should be considered.</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1267</li><li>➤ Ref:</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 1267</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient presented with acute pain in abdomen which radiated to the back and is relieved on sitting bent forwards. Acute pancreatitis is suspected. What is the most common etiology of acute pancreatitis?", "options": [{"label": "A", "text": "Alcohol", "correct": false}, {"label": "B", "text": "Post ERCP", "correct": false}, {"label": "C", "text": "Gallstones", "correct": true}, {"label": "D", "text": "Autoimmune", "correct": false}], "correct_answer": "C. Gallstones", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Gallstones</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Gallstone slipping into bile duct causing ampullary block is the most common cause of acute pancreatitis (world-wide).</li><li>• Gallstone slipping</li><li>• bile duct causing ampullary block</li><li>• most common cause of acute pancreatitis</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most common etiology of acute pancreatitis is gallstones , which can obstruct the ampulla and lead to pancreatic inflammation.</li><li>➤ most common etiology</li><li>➤ acute pancreatitis is gallstones</li><li>➤ obstruct the ampulla and lead to pancreatic inflammation.</li><li>➤ Causes of acute pancreatitis</li><li>➤ Causes of acute pancreatitis</li><li>➤ Gallstones/biliary Alcoholism Post ERCP Abdominal trauma Following biliary, upper gastrointestinal or cardiothoracic surgery Ampullary tumour Drugs (corticosteroids, azathioprine, asparaginase, valproic acid, thiazides, oestrogens) Hyperparathyroidism Hypercalcaemia Hypertriglyceridaemia Pancreas divisum Sphincter of Oddi dysfunction Autoimmune pancreatitis Hereditary pancreatitis Viral infections (mumps, coxsackie B) Malnutrition Scorpion bite Idiopathic</li><li>➤ Gallstones/biliary</li><li>➤ Alcoholism</li><li>➤ Post ERCP</li><li>➤ Abdominal trauma</li><li>➤ Following biliary, upper gastrointestinal or cardiothoracic surgery</li><li>➤ Ampullary tumour</li><li>➤ Drugs (corticosteroids, azathioprine, asparaginase, valproic acid, thiazides, oestrogens)</li><li>➤ Hyperparathyroidism</li><li>➤ Hypercalcaemia</li><li>➤ Hypertriglyceridaemia</li><li>➤ Pancreas divisum</li><li>➤ Sphincter of Oddi dysfunction</li><li>➤ Autoimmune pancreatitis</li><li>➤ Hereditary pancreatitis</li><li>➤ Viral infections (mumps, coxsackie B)</li><li>➤ Malnutrition</li><li>➤ Scorpion bite</li><li>➤ Idiopathic</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition 1270</li><li>➤ Ref:</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition 1270</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following metabolic abnormalities does not cause acute pancreatitis?", "options": [{"label": "A", "text": "Hyperkalemia", "correct": true}, {"label": "B", "text": "Hypercalcemia", "correct": false}, {"label": "C", "text": "Hyperparathyroidism", "correct": false}, {"label": "D", "text": "Hypertriglyceridemia", "correct": false}], "correct_answer": "A. Hyperkalemia", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A. Hyperkalaemia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Hypercalcemia can cause acute pancreatitis , particularly in conditions like hyperparathyroidism. High calcium levels can lead to calcium deposits in the pancreas, triggering inflammation.</li><li>• Option B:</li><li>• Hypercalcemia</li><li>• cause acute pancreatitis</li><li>• hyperparathyroidism.</li><li>• Option C: Hyperparathyroidism , which results in elevated levels of parathyroid hormone and calcium , can lead to acute pancreatitis due to calcium deposition in the pancreatic tissue.</li><li>• Option C:</li><li>• Hyperparathyroidism</li><li>• elevated levels of parathyroid hormone</li><li>• calcium</li><li>• Option D: Hypertriglyceridemia is a known cause of acute pancreatitis . Elevated triglycerides can lead to the development of pancreatitis, and severe cases may require treatment to lower triglyceride levels.</li><li>• Option D:</li><li>• Hypertriglyceridemia</li><li>• cause of acute pancreatitis</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Hyperkalemia is not associated with the development of acute pancreatitis , while hypercalcemia , hyperparathyroidism , and hypertriglyceridemia are potential risk factors for this condition.</li><li>➤ Hyperkalemia</li><li>➤ not associated with the development of acute pancreatitis</li><li>➤ hypercalcemia</li><li>➤ hyperparathyroidism</li><li>➤ hypertriglyceridemia</li><li>➤ Possible metabolic causes of acute pancreatitis</li><li>➤ Possible metabolic causes of acute pancreatitis</li><li>➤ Alcoholism Drugs (corticosteroids, azathioprine, asparaginase, valproic acid, thiazides, oestrogens) Hyperparathyroidism Hypercalcaemia Hypertriglyceridaemia Autoimmune pancreatitis Malnutrition Scorpion bite</li><li>➤ Alcoholism</li><li>➤ Drugs (corticosteroids, azathioprine, asparaginase, valproic acid, thiazides, oestrogens)</li><li>➤ Hyperparathyroidism</li><li>➤ Hypercalcaemia</li><li>➤ Hypertriglyceridaemia</li><li>➤ Autoimmune pancreatitis</li><li>➤ Malnutrition</li><li>➤ Scorpion bite</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition 1270</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition 1270</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient presented with an encapsulated peri-pancreatic fluid collection 6 weeks after an episode of acute pancreatitis. There was significant necrosis. Which of these is most likely according to the Atlanta classification?", "options": [{"label": "A", "text": "Acute peri pancreatic collection", "correct": false}, {"label": "B", "text": "Acute necrotic collection", "correct": false}, {"label": "C", "text": "Walled off necrosis", "correct": true}, {"label": "D", "text": "Pancreatic pseudocyst", "correct": false}], "correct_answer": "C. Walled off necrosis", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/screenshot-2024-03-28-182504.jpg"], "explanation": "<p><strong>Ans. C) Walled off necrosis.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Acute peri pancreatic collection: This term is used for fluid collections that occur within the first 4 weeks of acute pancreatitis and are not encapsulated.</li><li>• Option A:</li><li>• Acute peri pancreatic collection:</li><li>• fluid collections that occur within the first 4 weeks</li><li>• Option B: Acute necrotic collection: This term is used for fluid collections that contain both fluid and necrotic pancreatic or peripancreatic tissue and occur within the first 4 weeks of acute pancreatitis.</li><li>• Option B:</li><li>• Acute necrotic collection:</li><li>• fluid collections that contain both fluid and necrotic pancreatic</li><li>• Option D: Pancreatic pseudocyst: This term is used for encapsulated fluid collections that lack necrotic tissue and typically occur at least 4 weeks after an episode of acute pancreatitis.</li><li>• Option D:</li><li>• Pancreatic pseudocyst:</li><li>• encapsulated fluid collections that lack necrotic tissue</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ According to the Atlanta classification , in a patient with encapsulated peri-pancreatic fluid collection 6 weeks after an episode of acute pancreatitis with significant necrosis , the most likely classification is C. Walled off necrosis . This term is used for encapsulated collections containing both fluid and necrotic tissue that typically occur after 4 weeks of pancreatitis.</li><li>➤ Atlanta classification</li><li>➤ encapsulated peri-pancreatic fluid collection 6 weeks</li><li>➤ episode of acute pancreatitis</li><li>➤ necrosis</li><li>➤ C. Walled off necrosis</li><li>➤ Atlanta classification of pancreatic fluid collections-</li><li>➤ Atlanta classification of pancreatic fluid collections-</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1274</li><li>➤ Ref:</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 1274</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Pseudoaneurysm after acute pancreatitis most commonly affects which vessel?", "options": [{"label": "A", "text": "Gastro duodenal artery", "correct": false}, {"label": "B", "text": "Splenic artery", "correct": true}, {"label": "C", "text": "Superior mesenteric artery", "correct": false}, {"label": "D", "text": "Coeliac artery", "correct": false}], "correct_answer": "B. Splenic artery", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Splenic artery</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• The most common vessel affected by vascular complications of acute pancreatitis is the splenic artery , but the SMA , cystic artery , and gastroduodenal artery have also been found to be affected . It has been proposed that pancreatic elastase damages the vessels, leading to pseudoaneurysm formation. Spontaneous rupture results in massive bleeding. Clinical manifestations include sudden onset of abdominal pain, tachycardia, and hypotension. If possible, arterial embolization should be attempted to control the bleeding. Refractory cases require surgical ligation of the vessel affected. Pancreatic inflammation can also produce vascular thrombosis; the vessel usually affected is the splenic vein , but in severe cases, it can extend into the portal venous system leading to portal hypertension in the long term. Imaging demonstrates splenomegaly, gastric varices, and splenic vein occlusion. Thrombolytics have been described in the acute early phase; however, most patients can be managed with conservative treatment.</li><li>• The most common vessel affected by vascular complications of acute pancreatitis is the splenic artery , but the SMA , cystic artery , and gastroduodenal artery have also been found to be affected . It has been proposed that pancreatic elastase damages the vessels, leading to pseudoaneurysm formation. Spontaneous rupture results in massive bleeding.</li><li>• common vessel affected by vascular complications</li><li>• acute pancreatitis</li><li>• splenic artery</li><li>• SMA</li><li>• cystic artery</li><li>• gastroduodenal artery</li><li>• affected</li><li>• Clinical manifestations include sudden onset of abdominal pain, tachycardia, and hypotension.</li><li>• If possible, arterial embolization should be attempted to control the bleeding. Refractory cases require surgical ligation of the vessel affected.</li><li>• arterial embolization</li><li>• Pancreatic inflammation can also produce vascular thrombosis; the vessel usually affected is the splenic vein , but in severe cases, it can extend into the portal venous system leading to portal hypertension in the long term. Imaging demonstrates splenomegaly, gastric varices, and splenic vein occlusion. Thrombolytics have been described in the acute early phase; however, most patients can be managed with conservative treatment.</li><li>• vascular thrombosis; the vessel usually affected is the splenic vein</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In cases of pseudoaneurysm formation after acute pancreatitis , the most commonly affected vessel is the B. Splenic artery . This complication can lead to sudden onset abdominal pain , tachycardia , and hypotension , requiring intervention such as arterial embolization or surgical ligation.</li><li>➤ pseudoaneurysm formation</li><li>➤ acute pancreatitis</li><li>➤ B. Splenic artery</li><li>➤ lead to sudden onset abdominal pain</li><li>➤ tachycardia</li><li>➤ hypotension</li><li>➤ Ref: Sabiston Textbook of Surgery 20th Edition Page 1531</li><li>➤ Ref:</li><li>➤ Sabiston Textbook of Surgery 20th Edition Page 1531</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Criteria for SIRS include all of the following except", "options": [{"label": "A", "text": "Heart rate &gt; 90/min", "correct": false}, {"label": "B", "text": "pCO2 &lt; 32 mm Hg", "correct": false}, {"label": "C", "text": "BP &lt; 90/60 mm Hg", "correct": true}, {"label": "D", "text": "WBC count &gt; 12000 / mm3", "correct": false}], "correct_answer": "C. BP < 90/60 mm Hg", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) BP &lt;90/60 mm Hg</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Systemic Inflammatory Response Syndrome is defined by the presence of two or more of the following criteria :</li><li>• Systemic Inflammatory Response Syndrome</li><li>• presence of two or more of the following criteria</li><li>• Heart rate &gt;90/min Core temperature &lt;36°C or &gt;38°C Respirations &gt;20/min or PCO2 &lt;32 mmHg White blood cell count &lt;4000 or &gt;12 000/mm3</li><li>• Heart rate &gt;90/min</li><li>• Core temperature &lt;36°C or &gt;38°C</li><li>• Respirations &gt;20/min or PCO2 &lt;32 mmHg</li><li>• White blood cell count &lt;4000 or &gt;12 000/mm3</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1271</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1271</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the incorrect match with respect to revised Atlanta classification of acute pancreatitis-", "options": [{"label": "A", "text": "No local or systemic complications- Mild acute pancreatitis", "correct": false}, {"label": "B", "text": "Necrosis of 60% pancreas- Severe acute pancreatitis", "correct": true}, {"label": "C", "text": "Organ failure that resolves within 48 hours- Moderate acute pancreatitis", "correct": false}, {"label": "D", "text": "Persistent organ failure beyond 48 hours- Severe acute pancreatitis", "correct": false}], "correct_answer": "B. Necrosis of 60% pancreas- Severe acute pancreatitis", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Necrosis of 60% pancreas- Severe acute pancreatitis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Mild acute pancreatitis:</li><li>• Option A:</li><li>• Mild acute pancreatitis:</li><li>• No organ failure No local or systemic complications</li><li>• No organ failure</li><li>• No local or systemic complications</li><li>• Option C: Moderately acute pancreatitis:</li><li>• Option C:</li><li>• Moderately acute pancreatitis:</li><li>• Organ failure that resolves within 48 hours (transient organ failure) Local (fluid collections/necrosis) complications</li><li>• Organ failure that resolves within 48 hours (transient organ failure)</li><li>• Local (fluid collections/necrosis) complications</li><li>• Option D: Severe acute pancreatitis:</li><li>• Option D:</li><li>• Severe acute pancreatitis:</li><li>• Persistent organ failure (&gt;48 hours)</li><li>• Persistent organ failure (&gt;48 hours)</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Mild acute pancreatitis has no organ failure or complications , moderately severe acute pancreatitis includes transient organ failure or complications without persistent organ failure , and severe acute pancreatitis is defined by persistent organ failure , which can be either single or multiple organ failure lasting more than 48 hours.</li><li>➤ Mild acute pancreatitis</li><li>➤ no organ failure or complications</li><li>➤ moderately severe acute pancreatitis</li><li>➤ transient organ failure or complications without persistent organ failure</li><li>➤ severe acute pancreatitis</li><li>➤ persistent organ failure</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1271</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1271</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is an indication for surgical intervention in case of complicated acute pancreatitis?", "options": [{"label": "A", "text": "Renal failure", "correct": false}, {"label": "B", "text": "Infected necrotic collection", "correct": true}, {"label": "C", "text": "Sterile necrotic collection", "correct": false}, {"label": "D", "text": "Both B and C", "correct": false}], "correct_answer": "B. Infected necrotic collection", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Infected necrotic collection.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Though renal failure implies moderate/severe acute pancreatitis, it requires medical management.</li><li>• Option A: Though renal failure implies moderate/severe acute pancreatitis, it requires medical management.</li><li>• Option C: Sterile necrotic material should not be drained or interfered with.</li><li>• Option C:</li><li>• should not be</li><li>• In patients with necrosis of pancreas, if the patient shows signs of sepsis, then one should determine whether the collection is infected. Aspiration of fluid with a fine needle, percutaneously under CT or ultrasound guidance, can provide the answer. If the aspirate is purulent, drainage of the infected fluid should be carried out . Internal drainage into the stomach under endoscopic ultrasound guidance should be considered first. A plastic or covered metal stent can be used to create a communication between the collection and the gastric lumen. The stent may be left in for weeks if necessary and may need to be changed if blocked. If endoscopic internal drainage is not possible, then percutaneous drainage should be considered. The tube drain inserted should have the widest bore possible. Pancreatic necrosectomy should be considered if sepsis worsens despite conservative measures.</li><li>• In patients with necrosis of pancreas, if the patient shows signs of sepsis, then one should determine whether the collection is infected. Aspiration of fluid with a fine needle, percutaneously under CT or ultrasound guidance, can provide the answer.</li><li>• If the aspirate is purulent, drainage of the infected fluid should be carried out . Internal drainage into the stomach under endoscopic ultrasound guidance should be considered first. A plastic or covered metal stent can be used to create a communication between the collection and the gastric lumen. The stent may be left in for weeks if necessary and may need to be changed if blocked.</li><li>• is purulent, drainage of the infected fluid should be carried out</li><li>• If endoscopic internal drainage is not possible, then percutaneous drainage should be considered. The tube drain inserted should have the widest bore possible.</li><li>• Pancreatic necrosectomy should be considered if sepsis worsens despite conservative measures.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Management of necrotizing pancreatitis includes fine-needle aspiration to diagnose infection, endoscopic or percutaneous drainage for infected collections, and necrosectomy for persistent sepsis despite conservative treatment.</li><li>➤ Management of necrotizing pancreatitis</li><li>➤ fine-needle aspiration</li><li>➤ diagnose infection, endoscopic or percutaneous drainage</li><li>➤ infected collections,</li><li>➤ necrosectomy</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1275</li><li>➤ Ref:</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 1275</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient who is a known alcoholic was presented with complaints of chronic pain in the epigastric region with occasional flare-ups of the pain over a background discomfort. He also complains of greasy stools that stick to the pan. He has recently also developed diabetes. Which substance in stools can be measured to test for pancreatic function in this case?", "options": [{"label": "A", "text": "Lipase", "correct": false}, {"label": "B", "text": "Elastase", "correct": true}, {"label": "C", "text": "Calprotectin", "correct": false}, {"label": "D", "text": "Bile acids", "correct": false}], "correct_answer": "B. Elastase", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Elastase</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Lipase. While lipase is an enzyme produced by the pancreas , its measurement is typically used in the serum to diagnose acute pancreatitis, not in stool to assess chronic pancreatic function.</li><li>• Option A: Lipase.</li><li>• enzyme produced by the pancreas</li><li>• measurement</li><li>• used in the serum to diagnose acute pancreatitis,</li><li>• Option C: Calprotectin. Fecal calprotectin is a marker of inflammation in the gastrointestinal tract and is often used to test for inflammatory bowel diseases, not for pancreatic function.</li><li>• Option C: Calprotectin. Fecal calprotectin</li><li>• marker of inflammation in the gastrointestinal tract</li><li>• Option D: Bile acids. Bile acids are produced by the liver and their presence in stool is more indicative of bile acid malabsorption or ileal disease , rather than a direct measure of pancreatic function.</li><li>• Option D: Bile acids.</li><li>• produced by the liver and their presence in stool is more indicative of bile acid malabsorption or ileal disease</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The measurement of fecal elastase is a simple and specific test widely used to assess exocrine pancreatic function ; low levels in stools indicate pancreatic exocrine insufficiency.</li><li>➤ measurement of fecal elastase</li><li>➤ simple and specific test widely used to assess exocrine pancreatic function</li><li>➤ Pancreatic function tests-</li><li>➤ Pancreatic exocrine function can be assessed by directly measuring pancreatic secretion in response to a standardized stimulus. The stimulus to secretion can be physiological, e.g. ingestion of a test meal, as in the Lundh test, or pharmacological, e.g. intravenous injection of a hormone such as secretin or CCK. Duodenal intubation has to be performed with a triple-lumen tube so that the gastric and duodenal juices can be aspirated, and a non-absorbable marker such as polyethylene glycol is used to assess the completeness of the aspiration. The nitroblue tetrazolium – para-aminobenzoic acid (NBT –PABA) test provides an indirect measure of pancreatic function. The substance is administered orally and degraded in the gut by a pancreatic enzyme, and the breakdown product (PABA) is absorbed by the intestine and excreted in the urine; its urinary level is measured. The pancreolauryl test works on a similar principle. These tests are cheap and easy to perform but are non-specifi c . Measurement of the enzyme elastase in stool is simple, specific and now used widely. A low level of faecal elastase indicates exocrine insufficiency .</li><li>➤ Pancreatic exocrine function can be assessed by directly measuring pancreatic secretion in response to a standardized stimulus. The stimulus to secretion can be physiological, e.g. ingestion of a test meal, as in the Lundh test, or pharmacological, e.g. intravenous injection of a hormone such as secretin or CCK.</li><li>➤ ingestion of a test meal, as in the Lundh test, or pharmacological, e.g. intravenous injection of a hormone such as secretin or CCK.</li><li>➤ Duodenal intubation has to be performed with a triple-lumen tube so that the gastric and duodenal juices can be aspirated, and a non-absorbable marker such as polyethylene glycol is used to assess the completeness of the aspiration.</li><li>➤ The nitroblue tetrazolium – para-aminobenzoic acid (NBT –PABA) test provides an indirect measure of pancreatic function. The substance is administered orally and degraded in the gut by a pancreatic enzyme, and the breakdown product (PABA) is absorbed by the intestine and excreted in the urine; its urinary level is measured.</li><li>➤ The nitroblue tetrazolium</li><li>➤ –</li><li>➤ para-aminobenzoic acid (NBT</li><li>➤ –PABA)</li><li>➤ test provides an indirect</li><li>➤ its urinary level is measured.</li><li>➤ The pancreolauryl test works on a similar principle. These tests are cheap and easy to perform but are non-specifi c .</li><li>➤ The pancreolauryl test works on a similar principle.</li><li>➤ Measurement of the enzyme elastase in stool is simple, specific and now used widely. A low level of faecal elastase indicates exocrine insufficiency .</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1262-63</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1262-63</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient of chronic pancreatitis was seen to have a dilated pancreatic duct and multiple stones. What is the surgical procedure of choice in this case?", "options": [{"label": "A", "text": "Beger’s procedure", "correct": false}, {"label": "B", "text": "Distal pancreatectomy", "correct": false}, {"label": "C", "text": "Puestow’s procedure", "correct": true}, {"label": "D", "text": "Whipple’s procedure", "correct": false}], "correct_answer": "C. Puestow’s procedure", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture39.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture40.jpg"], "explanation": "<p><strong>Ans. C) Puestow’s procedure.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Beger’s procedure. The Beger procedure, also known as duodenum-preserving pancreatic head resection , is indicated for patients with inflammatory mass in the head of the pancreas . It preserves the duodenum and bile duct while removing part of the pancreatic head.</li><li>• Option A: Beger’s procedure.</li><li>• duodenum-preserving pancreatic head resection</li><li>• inflammatory mass in the head of the pancreas</li><li>• Option B: Distal pancreatectomy. A distal pancreatectomy involves removing the tail of the pancreas and is typically performed when the disease is limited to that part of the pancreas.</li><li>• Option B: Distal pancreatectomy.</li><li>• removing the tail of the pancreas</li><li>• Option D: Whipple’s procedure. The Whipple procedure, or pancreatoduodenectomy , is a more extensive surgery usually indicated for pancreatic cancer or complex cases where there is a mass in the head of the pancreas that may be causing obstruction.</li><li>• Option D: Whipple’s procedure.</li><li>• pancreatoduodenectomy</li><li>• more extensive surgery</li><li>• pancreatic cancer or complex cases</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Puestow procedure is indicated for chronic pancreatitis with a markedly dilated pancreatic duct , as it allows drainage of pancreatic secretions by connecting the duct to the jejunum.</li><li>➤ Puestow procedure</li><li>➤ chronic pancreatitis</li><li>➤ markedly dilated pancreatic duct</li><li>➤ allows drainage of pancreatic secretions</li><li>➤ Resectional procedures:</li><li>➤ Resectional procedures:</li><li>➤ Some patients have a mass in the head of the pancreas alone, for which either a pancreatoduodenectomy or a Beger procedure (duodenum-preserving resection of the pancreatic head) is appropriate. The rare patient with disease limited to the tail will be cured by a distal pancreatectomy.</li><li>➤ Some patients have a mass in the head of the pancreas alone, for which either a pancreatoduodenectomy or a Beger procedure (duodenum-preserving resection of the pancreatic head) is appropriate.</li><li>➤ Some patients have a mass in the head of the pancreas alone, for which either a pancreatoduodenectomy or a Beger procedure (duodenum-preserving resection of the pancreatic head) is appropriate.</li><li>➤ The rare patient with disease limited to the tail will be cured by a distal pancreatectomy.</li><li>➤ The rare patient with disease limited to the tail will be cured by a distal pancreatectomy.</li><li>➤ Drainage procedures:</li><li>➤ Drainage procedures:</li><li>➤ Patients with dilated duct and calculi are better managed by drainage procedures like Peusthow’s. Endoscopic procedures include endoscopic pancreatic sphincterotomy for papillary stenosis and sometimes ERCP for stone removal. Stent placement can be done in cases of dominant pancreatic duct structure and upstream dilatation.</li><li>➤ Patients with dilated duct and calculi are better managed by drainage procedures like Peusthow’s.</li><li>➤ Patients with dilated duct and calculi are better managed by drainage procedures like Peusthow’s.</li><li>➤ Endoscopic procedures include endoscopic pancreatic sphincterotomy for papillary stenosis and sometimes ERCP for stone removal. Stent placement can be done in cases of dominant pancreatic duct structure and upstream dilatation.</li><li>➤ Endoscopic procedures include endoscopic pancreatic sphincterotomy for papillary stenosis and sometimes ERCP for stone removal. Stent placement can be done in cases of dominant pancreatic duct structure and upstream dilatation.</li><li>➤ Combined procedures:</li><li>➤ Combined procedures:</li><li>➤ Where duct is dilated + head is inflamed- Head coring + Peusthow’s = Frey’s procedure</li><li>➤ Where duct is dilated + head is inflamed- Head coring + Peusthow’s = Frey’s procedure</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1279</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1279</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following mutations has the highest risk of pancreatic adenocarcinoma?", "options": [{"label": "A", "text": "STK 11", "correct": true}, {"label": "B", "text": "BRCA 1", "correct": false}, {"label": "C", "text": "APC", "correct": false}, {"label": "D", "text": "BRCA 2", "correct": false}], "correct_answer": "A. STK 11", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) STK 11</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: BRCA1 and D. BRCA2. BRCA1 (Breast Cancer 1) gene mutations are most notably associated with a higher risk for breast and ovarian cancers. Individuals with BRCA1 mutations also have an increased risk for other types of cancers, including ovarian, peritoneal, and pancreatic cancers.</li><li>• Option B: BRCA1 and D. BRCA2.</li><li>• gene mutations</li><li>• higher risk for breast and ovarian cancers.</li><li>• Option C. APC. APC (Adenomatous Polyposis Coli) gene mutations are primarily associated with familial adenomatous polyposis (FAP), which is characterized by the development of hundreds to thousands of polyps in the colon and rectum during the teenage years , and if untreated, increases the risk for colorectal cancer. APC mutations are also associated with other cancers such as stomach, small intestine, and pancreas.</li><li>• Option C. APC.</li><li>• gene mutations</li><li>• associated with familial adenomatous polyposis</li><li>• development of hundreds to thousands of polyps</li><li>• colon and rectum during the teenage years</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Recognize the specific cancer risks associated with genetic markers : STK11 is linked to Peutz-Jeghers syndrome and multiple cancer types ; BRCA1 and BRCA2 to breast and ovarian cancers, as well as other cancers; and APC to familial adenomatous polyposis and colorectal cancer .</li><li>➤ specific cancer risks</li><li>➤ genetic markers</li><li>➤ STK11 is linked to Peutz-Jeghers syndrome</li><li>➤ multiple cancer types</li><li>➤ BRCA1 and BRCA2 to breast and ovarian cancers,</li><li>➤ APC to familial adenomatous polyposis and colorectal cancer</li><li>➤ Risk factors for the development of pancreatic cancer .</li><li>➤ Risk factors for the development of pancreatic cancer</li><li>➤ Demographic factors -</li><li>➤ Demographic factors</li><li>➤ Age (peak incidence 65 – 75 years) Male gender Black ethnicity</li><li>➤ Age (peak incidence 65 – 75 years)</li><li>➤ Male gender</li><li>➤ Black ethnicity</li><li>➤ Environment/lifestyle-</li><li>➤ Environment/lifestyle-</li><li>➤ Cigarette smoking</li><li>➤ Cigarette smoking</li><li>➤ Genetic factors and medical conditions-</li><li>➤ Genetic factors and medical conditions-</li><li>➤ Family history -Two first-degree relatives with pancreatic cancer: relative risk increases 18- to 57-fold Germline BRCA2 mutations in some rare high-risk families (10 fold increase) Hereditary pancreatitis (50- to 70-fold increased risk) Chronic pancreatitis (5- to 15-fold increased risk) Lynch syndrome (HNPCC) (MLH 1 mutation) ( 8 fold increase) Ataxia telangiectasia Peutz – Jeghers syndrome (STK 11 mutation) (&gt;100 fold increase) Familial breast – ovarian cancer syndrome Familial atypical mole multiple melanoma syndrome (CDKN2A mutation) (&gt;40 fold increase) Familial adenomatous polyposis (APC mutation) – risk of ampullary/duodenal carcinoma Diabetes mellitus Obesity</li><li>➤ Family history -Two first-degree relatives with pancreatic cancer: relative risk increases 18- to 57-fold</li><li>➤ Germline BRCA2 mutations in some rare high-risk families (10 fold increase)</li><li>➤ Hereditary pancreatitis (50- to 70-fold increased risk)</li><li>➤ Chronic pancreatitis (5- to 15-fold increased risk)</li><li>➤ Lynch syndrome (HNPCC) (MLH 1 mutation) ( 8 fold increase)</li><li>➤ Ataxia telangiectasia</li><li>➤ Peutz – Jeghers syndrome (STK 11 mutation) (&gt;100 fold increase)</li><li>➤ Peutz</li><li>➤ –</li><li>➤ Jeghers syndrome (STK 11 mutation) (&gt;100 fold increase)</li><li>➤ Familial breast – ovarian cancer syndrome</li><li>➤ Familial atypical mole multiple melanoma syndrome (CDKN2A mutation) (&gt;40 fold increase)</li><li>➤ Familial adenomatous polyposis (APC mutation) – risk of ampullary/duodenal carcinoma</li><li>➤ Diabetes mellitus</li><li>➤ Obesity</li><li>➤ Ref: Bailey and Love ’ s Short Practice of Surgery 28th Edition Page 1281</li><li>➤ Ref:</li><li>➤ Bailey and Love</li><li>➤ ’</li><li>➤ s Short Practice of Surgery 28th Edition Page 1281</li><li>➤ Sabiston Textbook of Surgery 20th Edition Page 1542</li><li>➤ Sabiston Textbook of Surgery 20th Edition Page 1542</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following are correctly matched with respect to pancreatic tumors and their most common locations? i) Pancreatic adenocarcinoma- body / tail of pancreas ii) Serous cystadenoma- head of pancreas iii) Mucinous cystadenoma- body / tail of pancreas iv) Intraductal papillary mucinous neoplasm- head of pancreas", "options": [{"label": "A", "text": "i, ii", "correct": false}, {"label": "B", "text": "ii, iii", "correct": false}, {"label": "C", "text": "ii, iii and iv", "correct": true}, {"label": "D", "text": "ii, iv", "correct": false}], "correct_answer": "C. ii, iii and iv", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/screenshot-2024-03-28-182805.jpg"], "explanation": "<p><strong>Ans. C) ii,iii and iv.</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of the following are correct about non-functioning p ancreatic neuroendocrine tumou r except?", "options": [{"label": "A", "text": "Most common location is the head of the pancreas.", "correct": false}, {"label": "B", "text": "They stain positive for chromogranin A and synaptophysin", "correct": false}, {"label": "C", "text": "Present with non-specific symptoms like jaundice, abdominal pain and weight loss", "correct": false}, {"label": "D", "text": "Extremely poor prognosis", "correct": true}], "correct_answer": "D. Extremely poor prognosis", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D. Extremely poor prognosis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Most common location is the head of the pancreas. This statement is generally true for pancreatic tumors, including non-functioning pancreatic neuroendocrine tumors (PNETs), which often occur in the head of the pancreas, causing symptoms like jaundice due to bile duct obstruction.</li><li>• Option A: Most common location is the head of the pancreas.</li><li>• true</li><li>• Option B: They stain positive for chromogranin A and synaptophysin. This is correct . Non-functioning PNETs typically express markers such as chromogranin A and synaptophysin, which are used for their diagnosis.</li><li>• Option B: They stain positive for chromogranin A and synaptophysin.</li><li>• correct</li><li>• Option C: Present with non-specific symptoms like jaundice, abdominal pain, and weight loss. This is correct . Non-functioning PNETs often present with non-specific symptoms due to their slow growth and lack of hormonal symptoms, making them difficult to diagnose early.</li><li>• Option C: Present with non-specific symptoms like jaundice, abdominal pain, and weight loss.</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Non-functioning pancreatic neuroendocrine tumors often present with non-specific symptoms and are typically identified at a later stage . However, they are resectable and have a relatively good prognosis when compared to exocrine pancreatic tumors. They are characterized by positive staining for chromogranin A and synaptophysin.</li><li>➤ Non-functioning pancreatic neuroendocrine tumors</li><li>➤ non-specific symptoms</li><li>➤ identified at a later stage</li><li>➤ they are resectable</li><li>➤ good prognosis</li><li>➤ exocrine pancreatic tumors.</li><li>➤ They are generally diagnosed at a more advanced stage due to their indolent nature, slow growth, and lack of functional secretion . Symptoms are non-specific like jaundice, abdominal pain, weight, loss and pancreatitis. Some cases may present with liver metastasis. Can be easily identified by trans abdominal USG or CT scanning. They are resectable and have excellent long-term survival compared with their exocrine counterparts.</li><li>➤ They are generally diagnosed at a more advanced stage due to their indolent nature, slow growth, and lack of functional secretion . Symptoms are non-specific like jaundice, abdominal pain, weight, loss and pancreatitis. Some cases may present with liver metastasis.</li><li>➤ Can be easily identified by trans abdominal USG or CT scanning.</li><li>➤ They are resectable and have excellent long-term survival compared with their exocrine counterparts.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 908</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 908</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is characteristic of intra-ductal papillary mucinous neoplasm of pancreas?", "options": [{"label": "A", "text": "Bubble wrap appearance", "correct": false}, {"label": "B", "text": "Elevated CEA but normal amylase in cyst fluid", "correct": false}, {"label": "C", "text": "Mucus extruding from ampulla on ERCP", "correct": true}, {"label": "D", "text": "Ovary-like struma", "correct": false}], "correct_answer": "C. Mucus extruding from ampulla on ERCP", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C. Mucus extruding from ampulla on ERCP.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Bubble wrap appearance. Bubble wrap appearance is associated with serous cystadenoma of the pancreas , which is a different entity from intraductal papillary mucinous neoplasm (IPMN). Serous cystadenomas are benign cystic tumors characterized by a honeycomb appearance, sometimes described as resembling bubble wrap.</li><li>• Option A: Bubble wrap appearance.</li><li>• serous cystadenoma of the pancreas</li><li>• different entity from intraductal papillary mucinous neoplasm</li><li>• Option B: Elevated CEA but normal amylase in cyst fluid. While elevated CEA can be seen in the cyst fluid of IPMNs , it is not a characteristic feature, as CEA can also be elevated in other types of cystic pancreatic neoplasms like mucinous cystic neoplasm. Amylase can also be elevated in IPMNs due to the communication of the cystic structure with the pancreatic ductal system.</li><li>• Option B: Elevated CEA but normal amylase in cyst fluid.</li><li>• elevated CEA can be seen in the cyst fluid of IPMNs</li><li>• Option D: Ovary-like struma. Ovary-like stroma is a feature of mucinous cystic neoplasms (MCNs) with ovarian-type stroma , not IPMNs. MCNs are another subtype of mucin-producing cystic lesions of the pancreas.</li><li>• Option D: Ovary-like struma.</li><li>• mucinous cystic neoplasms</li><li>• ovarian-type stroma</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ Intraductal papillary mucinous neoplasms are characterized by the extrusion of mucus from the ampulla of Vater during ERCP , differentiating them from other pancreatic cystic lesions , such as serous cystadenomas with their \"bubble wrap\" appearance or mucinous cystic neoplasms with ovarian-type stroma.</li><li>➤ Intraductal papillary mucinous neoplasms</li><li>➤ extrusion of mucus from the ampulla of Vater during ERCP</li><li>➤ pancreatic cystic lesions</li><li>➤ serous cystadenomas with their \"bubble wrap\" appearance</li><li>➤ mucinous cystic</li><li>➤ Bubble wrap appearance is seen in serous cystadenoma (also shows starburst calcification) while thick walled multiloculated cysts are seen in mucinous cystadenoma.</li><li>➤ Bubble wrap appearance is seen in serous cystadenoma (also shows starburst calcification) while thick walled multiloculated cysts are seen in mucinous cystadenoma.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1281</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1281</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Match the following-", "options": [{"label": "A", "text": "1-a, 2-b, 3-c, 4-d", "correct": false}, {"label": "B", "text": "1-c, 2-d, 3-a, 4-b", "correct": false}, {"label": "C", "text": "1-b, 2-d, 3-d, 4-c", "correct": false}, {"label": "D", "text": "1-c, 2-d, 3-b, 4-a", "correct": true}], "correct_answer": "D. 1-c, 2-d, 3-b, 4-a", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/screenshot-2024-03-28-182927.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/1245.jpg"], "explanation": "<p><strong>Ans. D.1-c, 2-d,3-b, 4-a.</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "The splenic artery runs through which of these primarily to supply the spleen?", "options": [{"label": "A", "text": "Lienorenal ligament", "correct": true}, {"label": "B", "text": "Gastrosplenic ligament", "correct": false}, {"label": "C", "text": "Phrenocolic ligament", "correct": false}, {"label": "D", "text": "Lesser omentum", "correct": false}], "correct_answer": "A. Lienorenal ligament", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A. Lienorenal ligament</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Gastrosplenic ligament. The gastrosplenic ligament, also known as the gastrolienal ligament, connects the spleen to the greater curvature of the stomach and carries short gastric vessels and the left gastroepiploic vessels but is not the primary pathway for the splenic artery.</li><li>• Option B: Gastrosplenic ligament.</li><li>• short gastric vessels and the left gastroepiploic vessels but is not the</li><li>• Option C: Phrenocolic ligament. The phrenocolic ligament connects the splenic flexure of the colon to the diaphragm and runs inferior and lateral to the lower pole of the spleen but does not contain the splenic artery.</li><li>• Option C: Phrenocolic ligament.</li><li>• connects the splenic flexure</li><li>• colon to the diaphragm</li><li>• runs inferior and lateral to the lower pole of the spleen</li><li>• Option D: Lesser omentum. The lesser omentum connects the stomach and the first part of the duodenum to the liver . It does not primarily contain the splenic artery.</li><li>• Option D: Lesser omentum.</li><li>• connects the stomach and the first part of the duodenum to the liver</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The splenic artery primarily runs through the lienorenal (splenorenal) ligament to supply the spleen . This ligament connects the spleen to the left kidney and carries the splenic vessels and the tail of the pancreas.</li><li>➤ splenic artery primarily runs through the lienorenal</li><li>➤ ligament to supply the spleen</li><li>➤ Ligaments of spleen:</li><li>➤ Ligaments of spleen:</li><li>➤ The phrenocolic ligament prevents the downward displacement of the spleen. It connects the splenic flexure of the colon to the diaphragm runs inferior and lateral to the lower pole of the spleen. The spleen is connected to the stomach and kidney by a double fold of peritoneum that originates from the stomach as a part of the greater omentum. The gastrosplenic (gastrolienal) ligament is anterior to the splenic hilum and connects the spleen to the greater curvature of the stomach.</li><li>➤ The phrenocolic ligament prevents the downward displacement of the spleen. It connects the splenic flexure of the colon to the diaphragm runs inferior and lateral to the lower pole of the spleen.</li><li>➤ prevents the downward displacement</li><li>➤ The spleen is connected to the stomach and kidney by a double fold of peritoneum that originates from the stomach as a part of the greater omentum.</li><li>➤ The gastrosplenic (gastrolienal) ligament is anterior to the splenic hilum and connects the spleen to the greater curvature of the stomach.</li><li>➤ Ref : Bailey 28 th Ed. Pg 1219</li><li>➤ Ref : Bailey 28 th Ed. Pg 1219</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "What the most common site of accessory spleen?", "options": [{"label": "A", "text": "Splenic hilum", "correct": true}, {"label": "B", "text": "Gastrocolic ligament", "correct": false}, {"label": "C", "text": "Phrenocolic ligament", "correct": false}, {"label": "D", "text": "Splenocolic ligament", "correct": false}], "correct_answer": "A. Splenic hilum", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A. Splenic hilum</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Splenunculi are single or multiple accessory spleens that are found in approximately 10–30% of the population. They are located near the hilum of the spleen in 50% of cases and are related to the splenic vessels, or behind the tail of the pancreas in 30%.</li><li>• Splenunculi</li><li>• single or multiple accessory spleens</li><li>• found in approximately 10–30% of the population.</li><li>• near the hilum of the spleen in 50% of cases</li><li>• The remaining is located in the mesocolon , greater omentum or the splenic ligaments . Their significance lies in the fact that failure to identify and remove these at the time of splenectomy may give rise to persistent disease.</li><li>• remaining is located in the mesocolon</li><li>• greater omentum</li><li>• splenic ligaments</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ The most common site of an accessory spleen is the splenic hilum , found in 50% of cases with accessory spleens , followed by tail of pancreas (30%).</li><li>➤ most common site of an accessory spleen is the splenic hilum</li><li>➤ 50% of cases with accessory spleens</li><li>➤ tail of pancreas</li><li>➤ Ref : Bailey: 28 th Ed. Pg 1222</li><li>➤ Ref : Bailey: 28 th Ed. Pg 1222</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is the incorrect statement with respect to the anatomy of the spleen?", "options": [{"label": "A", "text": "The splenic vein drains into the main Portal vein", "correct": false}, {"label": "B", "text": "The spleen is usually located between the 11th to 12th ribs", "correct": true}, {"label": "C", "text": "The hilum of the spleen sits in the angle between the stomach and the kidney and is in contact with the tail of the pancreas", "correct": false}, {"label": "D", "text": "Fetal splenic tissue develops from condensation of mesoderm", "correct": false}], "correct_answer": "B. The spleen is usually located between the 11th to 12th ribs", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B. The spleen is usually located between the 11thto 12thribs</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A : The splenic vein is formed from several tributaries that drain the hilum and runs behind the pancreas , receiving several small tributaries from the pancreas before joining the superior mesenteric vein at the neck of the pancreas to form the portal vein.</li><li>• Option A</li><li>• splenic vein is formed from several tributaries</li><li>• drain the hilum and runs behind the pancreas</li><li>• Option C : The hilum of the spleen sits in the angle between the stomach and the kidney and is in contact with the tail of the pancreas . The concave visceral surface lies in contact with these structures, and the lower pole extends no further than the midaxillary line. There is a notch on the inferolateral border, and this may be palpated only when the spleen is enlarged.</li><li>• Option C</li><li>• hilum of the spleen sits in the angle between the stomach and the kidney</li><li>• contact with the tail of the pancreas</li><li>• There is a notch on the inferolateral border, and this may be palpated only when the spleen is enlarged.</li><li>• Option D : Fetal splenic tissue develops from condensations of mesoderm in the dorsal mesogastrium . This peritoneal fold attaches the dorsal body wall to the fusiform swelling in the foregut that develops into the stomach. This condensation divides the mesogastrium into two parts, one between the fetal splenic tissue and the stomach to form the gastrosplenic ligament and the other between it and the left kidney to form the lienorenal ligament.</li><li>• Option D</li><li>• Fetal splenic tissue</li><li>• condensations of mesoderm in the dorsal mesogastrium</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ The incorrect statement regarding the anatomy of the spleen is that the spleen is usually located between the 11th to 12th ribs. The spleen actually resides in the left hypochondrium , along the axis of the 10th rib, and extends from the 9th to the 11th ribs.</li><li>➤ incorrect statement regarding the anatomy of the spleen is that the spleen</li><li>➤ between the 11th to 12th ribs.</li><li>➤ spleen</li><li>➤ resides in the left hypochondrium</li><li>➤ Ref : Bailey: 28 th Ed. Pg 1219</li><li>➤ Ref : Bailey: 28 th Ed. Pg 1219</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following substances correctly describes the inflation of the distal balloon of the tube below?", "options": [{"label": "A", "text": "300 cc air", "correct": true}, {"label": "B", "text": "300cc saline", "correct": false}, {"label": "C", "text": "30cc air", "correct": false}, {"label": "D", "text": "30cc saline", "correct": false}], "correct_answer": "A. 300 cc air", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture44.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. A. 300cc air</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• The shown image is the Sengstaken-Blakemore triple lumen tube , with distal gastric and proximal esophageal balloon . Gastric balloon is inflated with 300 cc air.</li><li>• Sengstaken-Blakemore triple lumen tube</li><li>• distal gastric</li><li>• proximal esophageal balloon</li><li>• Gastric balloon is inflated with 300 cc air.</li><li>• Balloon tamponade is effective for massive or refractory variceal bleeding but is only recommended as a ‘bridge’ to definitive treatment . If the rate of blood loss prohibits endoscopic evaluation , a triple lumen Sengstaken–Blakemore tube or a 4-lumen Minnesota tube (addition of an esophageal aspiration port) can be inserted to provide temporary haemostasis.</li><li>• Balloon tamponade</li><li>• massive or refractory variceal bleeding</li><li>• ‘bridge’ to definitive treatment</li><li>• rate of blood loss prohibits endoscopic evaluation</li><li>• triple lumen Sengstaken–Blakemore tube</li><li>• 4-lumen Minnesota tube</li><li>• Once inserted , the gastric balloon is inflated with 300 mL of air and retracted to the gastric fundus and the esophago- gastric varices tamponaded by inflation of the esophageal balloon to 60 mmHg.</li><li>• Once inserted</li><li>• gastric balloon is inflated with 300 mL of air</li><li>• retracted to the gastric fundus</li><li>• esophago- gastric varices tamponaded by inflation</li><li>• esophageal balloon to 60 mmHg.</li><li>• The two remaining channels allow gastric and esophageal aspiration and the position of the tube is confirmed radiologically.</li><li>• two remaining channels allow gastric and esophageal aspiration</li><li>• A strict protocol for the management of balloon tamponade is important to avoid complications particularly esophageal pressure necrosis .</li><li>• strict protocol</li><li>• management of balloon tamponade</li><li>• avoid complications particularly esophageal pressure necrosis</li><li>• Ref : Bailey 28 th Ed. Pg1204-05</li><li>• Ref : Bailey 28 th Ed. Pg1204-05</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is incorrect regarding endoscopic management of variceal bleed?", "options": [{"label": "A", "text": "Banding has lower rebleed risk than sclerotherapy", "correct": false}, {"label": "B", "text": "All visible varices should be banded/sclerosed.", "correct": true}, {"label": "C", "text": "If patient has rebleed, another attempt at endoscopic management may be done.", "correct": false}, {"label": "D", "text": "Gastric varices are managed by cyanoacrylate glue injection.", "correct": false}], "correct_answer": "B. All visible varices should be banded/sclerosed.", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture46.jpg"], "explanation": "<p><strong>Ans. B. All visible varices should be banded/sclerosed.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Banding has lower rebleed risk than sclerotherapy This is correct . Banding, or endoscopic variceal ligation, is preferred over sclerotherapy because it is associated with fewer complications and a lower risk of rebleeding.</li><li>• Option A: Banding has lower rebleed risk than sclerotherapy</li><li>• correct</li><li>• Option C: If a patient has a rebleed, another attempt at endoscopic management may be done This is correct . If a patient experiences rebleeding, a second attempt at endoscopic intervention can be made to control the hemorrhage.</li><li>• Option C: If a patient has a rebleed, another attempt at endoscopic management may be done</li><li>• correct</li><li>• Option D: Gastric varices are managed by cyanoacrylate glue injection This is correct . Injection of cyanoacrylate glue is an effective method for managing bleeding gastric varices.</li><li>• Option D: Gastric varices are managed by cyanoacrylate glue injection</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In the endoscopic management of variceal bleeding , not all visible varices should be treated ; only the bleeding varices or those at high risk of bleeding are targeted for banding or sclerotherapy.</li><li>➤ endoscopic management of variceal bleeding</li><li>➤ not all visible varices should be treated</li><li>➤ bleeding varices</li><li>➤ high risk of bleeding</li><li>➤ The two most commonly used endoscopic techniques are endoscopic band ligation to the base of the varix and injection of a sclerosant into or around the varix. Following resuscitation, endoscopy is performed in a head-down position with good suction available. When the bleeding varix or varices are identified, only the source should be treated. Sclerotherapy or banding both achieve effective control with banding reducing rebleeding; a single treatment is usually sufficient.</li><li>➤ The two most commonly used endoscopic techniques are endoscopic band ligation to the base of the varix and injection of a sclerosant into or around the varix.</li><li>➤ Following resuscitation, endoscopy is performed in a head-down position with good suction available. When the bleeding varix or varices are identified, only the source should be treated.</li><li>➤ When the bleeding varix or varices are identified, only the source should be treated.</li><li>➤ Sclerotherapy or banding both achieve effective control with banding reducing rebleeding; a single treatment is usually sufficient.</li><li>➤ Ref : Bailey: 28 th Ed. Pg 1204-05</li><li>➤ Ref</li><li>➤ : Bailey: 28 th Ed. Pg 1204-05</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the incorrect statement regarding the management of portal HTN?", "options": [{"label": "A", "text": "Devascularisation procedure with splenectomy is called Sugiura Futugawa procedure", "correct": false}, {"label": "B", "text": "Alpha blockers like Prazosin can be used for elective medical management in portal HTN", "correct": true}, {"label": "C", "text": "Lintons shunt is used for hypersplenism", "correct": false}, {"label": "D", "text": "TIPSS can be done under local anesthesia", "correct": false}], "correct_answer": "B. Alpha blockers like Prazosin can be used for elective medical management in portal HTN", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B. Alpha blockers like Prazosin can be used for elective medical management in portal hypertension.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A : The Sugiura procedure for esophageal varices combines splenectomy with oesophagogastric devascularisation , permanently interrupting the intraoesophageal portacaval shunt while preserving perioesophageal varices.</li><li>• Option A</li><li>• Sugiura procedure for esophageal varices</li><li>• splenectomy</li><li>• oesophagogastric devascularisation</li><li>• Option C : Linton's splenorenal shunt : Before the spleen is removed , the splenic vein is dissected at the splenic porta so that the maximum length of the vein is available . Next, the left renal vein is isolated so that the surgeon can determine where in its course the splenic vein lies closest to the renal vein. The segment of the splenic vein lying on the posterior aspect of the pancreas is then dissected. Once an optimal length of splenic vein has been obtained, an end-to-side splenorenal anastomosis is performed.</li><li>• Option C</li><li>• Linton's splenorenal shunt</li><li>• Before the spleen is removed</li><li>• splenic vein is dissected at the splenic porta</li><li>• maximum length of the vein is available</li><li>• Option D : A TIPSS is inserted via the internal jugular vein , superior vena cava and hepatic vein , where in a guidewire is inserted through the hepatic parenchyma into a branch of the portal vein .</li><li>• Option D</li><li>• TIPSS is inserted via the internal jugular vein</li><li>• superior vena cava</li><li>• hepatic vein</li><li>• guidewire is inserted</li><li>• hepatic parenchyma</li><li>• branch of the portal vein</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Alpha blockers like prazosin are not used for the elective medical management of portal hypertension ; rather, non-selective beta blockers such as propranolol are employed for their splanchnic vasoconstrictive effects.</li><li>➤ Alpha blockers</li><li>➤ prazosin are not used for the elective medical management</li><li>➤ portal hypertension</li><li>➤ non-selective beta blockers</li><li>➤ propranolol</li><li>➤ splanchnic vasoconstrictive effects.</li><li>➤ Ref : Bailey 28 th Ed. Pg 1205-06</li><li>➤ Ref : Bailey 28 th Ed. Pg 1205-06</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In patients with secondary metastasis to liver, most common primary site is?", "options": [{"label": "A", "text": "Gall bladder adenocarcinoma", "correct": false}, {"label": "B", "text": "Pancreatic adenocarcinoma", "correct": false}, {"label": "C", "text": "Stomach adenocarcinoma", "correct": false}, {"label": "D", "text": "Colo-rectal adenocarcinoma", "correct": true}], "correct_answer": "D. Colo-rectal adenocarcinoma", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Colo-rectal adenocarcinoma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Gall bladder adenocarcinoma. While gall bladder cancers can metastasize to the liver due to the proximity of the gallbladder to the liver , they are not the most common source of liver metastases.</li><li>• Option A: Gall bladder adenocarcinoma.</li><li>• metastasize to the liver</li><li>• proximity of the gallbladder to the liver</li><li>• not the most common source of liver metastases.</li><li>• Option B: Pancreatic adenocarcinoma. Pancreatic cancer can metastasize to the liver , but like gall bladder adenocarcinoma, it is not the most common primary source of liver metastases.</li><li>• Option B: Pancreatic adenocarcinoma.</li><li>• metastasize to the liver</li><li>• not the most common primary source of liver metastases.</li><li>• Option C: Stomach adenocarcinoma. Stomach or gastric cancers can spread to the liver , but colorectal cancer is more commonly associated with liver metastases.</li><li>• Option C: Stomach adenocarcinoma.</li><li>• gastric cancers</li><li>• spread to the liver</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most common primary cancer to metastasize to the liver is colorectal adenocarcinoma, with a significant proportion of patients developing synchronous or metachronous liver metastases .</li><li>➤ most common primary cancer to metastasize to the liver is colorectal adenocarcinoma,</li><li>➤ patients developing synchronous or metachronous liver metastases</li><li>➤ Worldwide colorectal cancer (CRC) is the third most common solid organ malignancy and the fourth most common cause of cancer-related deaths .</li><li>➤ Worldwide colorectal cancer</li><li>➤ third most common solid organ malignancy</li><li>➤ fourth most common cause of cancer-related deaths</li><li>➤ Up to 70% of patients with CRC develop synchronous (15–25%) or metachronous (20–45%) liver metastases.</li><li>➤ Ref: Bailey 28 th Ed. Pg 1216</li><li>➤ Ref: Bailey 28 th Ed. Pg 1216</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "What is the length of the common bile duct?", "options": [{"label": "A", "text": "5.5 cm", "correct": false}, {"label": "B", "text": "6.5 cm", "correct": false}, {"label": "C", "text": "7.5 cm", "correct": true}, {"label": "D", "text": "8.5 cm", "correct": false}], "correct_answer": "C. 7.5 cm", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) 7.5cm</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• The common bile duct (CBD) is about 7.5 cm long and is formed by the junction of the cystic and common hepatic ducts . It is divided into four parts:</li><li>• common bile duct</li><li>• 7.5 cm long</li><li>• formed by the junction of the cystic</li><li>• common hepatic ducts</li><li>• four parts:</li><li>• Supra-duodenal portion , about 2.5 cm long, runs in the free edge of the lesser omentum. Retro-duodenal portion. Infra-duodenal portion lies in a groove, at times in a tunnel, on the posterior surface of the pancreas. Intra-duodenal portion passes obliquely through the wall of the second part of the duodenum, where it is surrounded by the sphincter of Oddi and terminates by opening on the summit of the ampulla of Vater.</li><li>• Supra-duodenal portion , about 2.5 cm long, runs in the free edge of the lesser omentum.</li><li>• Supra-duodenal portion</li><li>• Retro-duodenal portion.</li><li>• Retro-duodenal portion.</li><li>• Infra-duodenal portion lies in a groove, at times in a tunnel, on the posterior surface of the pancreas.</li><li>• Infra-duodenal portion</li><li>• Intra-duodenal portion passes obliquely through the wall of the second part of the duodenum, where it is surrounded by the sphincter of Oddi and terminates by opening on the summit of the ampulla of Vater.</li><li>• Intra-duodenal portion</li><li>• Ref: Bailey and Love 28 th Ed. Pg 1232</li><li>• Ref:</li><li>• Bailey and Love 28 th Ed. Pg 1232</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old male patient underwent a routine USG following which this finding was noted. What is FALSE regarding the above condition?", "options": [{"label": "A", "text": "Man is the dead end host", "correct": false}, {"label": "B", "text": "FNAC is contraindicated", "correct": false}, {"label": "C", "text": "PAIR is the treatment of choice in cysto-biliary communication", "correct": true}, {"label": "D", "text": "Echinococcus parasite is the causative agent", "correct": false}], "correct_answer": "C. PAIR is the treatment of choice in cysto-biliary communication", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture14.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) PAIR is the treatment of choice in cysto-biliary communication.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Man is the dead-end host, Option D: Echinococcus is causative. Echinococcus granulosus , the causative agent of hydatid disease , has a life cycle that involves dogs (definitive host) and sheep (intermediate host). Humans become accidental intermediate hosts by ingesting ova through contaminated food, water, or direct contact with dog feces . Once ingested, the eggs hatch in the intestines, and the larvae can migrate through the portal vein (PV) to various organs, most commonly the liver, where they form hydatid cysts. This is considered a dead-end in the parasite's life cycle because humans are not a part of the natural transmission cycle.</li><li>• Option A: Man is the dead-end host, Option D: Echinococcus is causative. Echinococcus granulosus</li><li>• causative agent of hydatid disease</li><li>• life cycle that involves dogs</li><li>• sheep</li><li>• Humans become accidental intermediate hosts by ingesting ova through contaminated food, water, or direct contact</li><li>• dog feces</li><li>• Option B: For conditions like echinococcus (hydatid) cysts , FNAC is contraindicated due to the risk of anaphylaxis and spread of infection</li><li>• Option B:</li><li>• echinococcus</li><li>• cysts</li><li>• FNAC is contraindicated due to the risk of anaphylaxis and spread of infection</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Echinococcus granulosus , a parasite with a life cycle involving dogs and sheep, causes hydatid disease in humans who are accidental hosts. PAIR treatment is contraindicated in cases of hydatid cysts with cysto-biliary communication due to the risk of biliary leak and cholangitis.</li><li>➤ Echinococcus granulosus</li><li>➤ parasite with a life cycle</li><li>➤ dogs and sheep, causes hydatid disease in humans</li><li>➤ accidental hosts.</li><li>➤ PAIR treatment</li><li>➤ contraindicated in cases of hydatid cysts</li><li>➤ cysto-biliary communication</li><li>➤ biliary leak and cholangitis.</li><li>➤ Ref: Bailey and Love 28 th Ed. Pg 73-76</li><li>➤ Ref: Bailey and Love 28 th Ed. Pg 73-76</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the incorrect statement about hydatid cyst disease in humAns.", "options": [{"label": "A", "text": "According to WHO classification, type 1 hydatid cysts are inactive", "correct": true}, {"label": "B", "text": "Elective clinical presentation is usually in the form of a lump arising from the liver", "correct": false}, {"label": "C", "text": "Anaphylactic shock due to rupture of the hydatid cyst is the emergency presentation", "correct": false}, {"label": "D", "text": "CT scan is the diagnostic test", "correct": false}], "correct_answer": "A. According to WHO classification, type 1 hydatid cysts are inactive", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/screenshot-2024-03-28-181350.jpg"], "explanation": "<p><strong>Ans. A) According to WHO classification, type 1 hydatid cysts are inactive.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Elective clinical presentation is usually in the form of a lump arising from the liver. Hydatid cysts can indeed present as a lump or mass in the liver , which may or may not be painful . The presentation can vary from asymptomatic to causing discomfort due to the mass effect.</li><li>• Option B: Elective clinical presentation is usually in the form of a lump arising from the liver.</li><li>• Hydatid cysts</li><li>• present as a lump or mass in the liver</li><li>• may or may not be painful</li><li>• Option C: Anaphylactic shock due to rupture of the hydatid cyst is the emergency presentation. Rupture of a hydatid cyst can lead to anaphylactic shock , which is a severe allergic reaction and is considered an emergency presentation. This statement is correct .</li><li>• Option C: Anaphylactic shock due to rupture of the hydatid cyst is the emergency presentation.</li><li>• Rupture of a hydatid cyst</li><li>• anaphylactic shock</li><li>• severe allergic reaction</li><li>• correct</li><li>• Option D: CT scan is the diagnostic test. CT scans are highly effective in the imaging and diagnosis of hydatid cysts , providing detailed images that help in identifying the characteristic features of the cysts, such as their outline and internal structure.</li><li>• Option D: CT scan is the diagnostic test.</li><li>• highly effective in the imaging and diagnosis of hydatid cysts</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The WHO Informal Working Group on Echinococcosis (WHO-IWGE) proposed a standardized ultrasound classification based on the status of activity of the cyst . This is universally accepted, particularly because it helps to decide on the appropriate management. Three groups have been recognized:</li><li>➤ WHO Informal Working Group on Echinococcosis</li><li>➤ standardized ultrasound classification based on the status of activity of the cyst</li><li>➤ Group 1 : Active group – cysts larger than 2 cm and often fertile. Group 2 : Transition group – cysts starting to degenerate and entering a transitional stage because of host resistance or treatment but may contain viable protoscolices. Group 3 : Inactive group – degenerated, partially or totally calcified cysts; unlikely to contain viable protoscolices.</li><li>➤ Group 1 : Active group – cysts larger than 2 cm and often fertile.</li><li>➤ Group 1</li><li>➤ Group 2 : Transition group – cysts starting to degenerate and entering a transitional stage because of host resistance or treatment but may contain viable protoscolices.</li><li>➤ Group 2</li><li>➤ Group 3 : Inactive group – degenerated, partially or totally calcified cysts; unlikely to contain viable protoscolices.</li><li>➤ Group 3</li><li>➤ Ultrasonography and CT scan are the investigations of choice . The CT scan shows a smooth space-occupying lesion with several septa. Radical total or partial pericystectomy with omentoplasty or hepatic segmentectomy (especially if the lesion is in a peripheral part of the liver) are some of the surgical options . During the operation, scolicidal agents are used, such as hypertonic saline (15–20%), ethanol (75–95%) or 5% povidone–iodine (although some use a 10% solution). This may cause sclerosing cholangitis if biliary radicles are in communication with the cyst wall.</li><li>➤ Ultrasonography and CT scan are the investigations of choice . The CT scan shows a smooth space-occupying lesion with several septa.</li><li>➤ Ultrasonography and CT scan are the investigations of choice</li><li>➤ Radical total or partial pericystectomy with omentoplasty or hepatic segmentectomy (especially if the lesion is in a peripheral part of the liver) are some of the surgical options . During the operation, scolicidal agents are used, such as hypertonic saline (15–20%), ethanol (75–95%) or 5% povidone–iodine (although some use a 10% solution). This may cause sclerosing cholangitis if biliary radicles are in communication with the cyst wall.</li><li>➤ Radical total or partial pericystectomy with omentoplasty or hepatic segmentectomy</li><li>➤ some of the surgical options</li><li>➤ Ref: Bailey and Love 28 th Ed. Pg 73-75</li><li>➤ Ref:</li><li>➤ Bailey and Love 28 th Ed. Pg 73-75</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is incorrect about pulmonary hydatid cyst disease?", "options": [{"label": "A", "text": "Symptomatic patients present with cough, expectoration, fever, and haemoptysis", "correct": false}, {"label": "B", "text": "Capitonnage is done for pulmonary hydatids", "correct": false}, {"label": "C", "text": "Meniscus sign implies impending rupture of cyst", "correct": false}, {"label": "D", "text": "Medical management is the mainstay", "correct": true}], "correct_answer": "D. Medical management is the mainstay", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Medical management is the mainstay.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• The mainstay of treatment of pulmonary hydatid is surgery. Medical treatments are less successful and considered when surgery is not possible because of poor general condition or diffuse disease affecting both lungs , or recurrent or ruptured cysts.</li><li>• The mainstay of treatment of pulmonary hydatid is surgery. Medical treatments are less successful</li><li>• surgery is not possible because of poor general condition</li><li>• diffuse disease affecting both lungs</li><li>• Option A: Symptomatic patients present with cough, expectoration, fever, and haemoptysis. This is a correct statement. Symptomatic patients with pulmonary hydatid cyst disease can present with these respiratory symptoms as the cysts in the lungs cause irritation and inflammation.</li><li>• Option A: Symptomatic patients present with cough, expectoration, fever, and haemoptysis.</li><li>• correct statement.</li><li>• Option B: Capitonnage is done for pulmonary hydatids. Capitonnage is a surgical technique used in the treatment of pulmonary hydatid disease . It involves the obliteration of the residual cavity after the removal of a hydatid cyst to prevent space problems and secondary infection. This is a correct statement.</li><li>• Option B: Capitonnage is done for pulmonary hydatids.</li><li>• Capitonnage</li><li>• surgical technique</li><li>• treatment of pulmonary hydatid disease</li><li>• Option C: Meniscus sign implies impending rupture of cyst. The meniscus or crescent sign refers to the appearance of air between the pericyst and the ectocyst of a hydatid cyst on imaging studies . It can indicate that the cyst is under tension and may be at risk of rupture. This statement is also correct.</li><li>• Option C: Meniscus sign implies impending rupture of cyst.</li><li>• meniscus or crescent sign</li><li>• appearance of air between the pericyst</li><li>• ectocyst of a hydatid cyst on imaging studies</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The primary treatment for pulmonary hydatid cyst disease is surgical resection , with medical management playing a secondary role , often when surgery is not possible due to the patient's condition or when the disease is too diffuse.Top of</li><li>➤ primary treatment for pulmonary hydatid cyst disease is surgical resection</li><li>➤ medical management playing a secondary role</li><li>➤ The lung is the second commonest organ affected after the liver . The size of the cyst can vary from very small to a considerable size. The right lung and lower lobes are slightly more often involved. The cyst is usually single, although multiple cysts do occur and concomitant hydatid cysts in other organs, such as the liver, are not unknown. The condition may be silent and found incidentally. Symptomatic patients present with cough, expectoration, fever, chest pain and sometimes haemoptysis. Silent cysts may present as an emergency because of rupture or an allergic reaction. Uncomplicated cysts present as rounded or oval lesions on chest radiography. Erosion of the bronchioles results in air being introduced between the pericyst and the laminated membrane and gives a fine radiolucent crescent, the ‘meniscus’ or ‘crescent’ sign. This is often regarded as a sign of impending rupture. When the cyst ruptures, the crumpled collapsed endocyst floats like a lily on the residual fluid, giving rise to the ‘water-lily’ sign on CT scan. Rupture into the pleural cavity results in pleural effusion. CT scan defines the pathology in greater detail. The principle of surgery is to preserve as much viable lung tissue as possible. The exact procedure can vary: cystotomy, capitonnage, pericystectomy, segmentectomy or occasionally pneumonectomy</li><li>➤ The lung is the second commonest organ affected after the liver . The size of the cyst can vary from very small to a considerable size.</li><li>➤ lung is the second commonest organ affected after the liver</li><li>➤ The right lung and lower lobes are slightly more often involved. The cyst is usually single, although multiple cysts do occur and concomitant hydatid cysts in other organs, such as the liver, are not unknown.</li><li>➤ The condition may be silent and found incidentally. Symptomatic patients present with cough, expectoration, fever, chest pain and sometimes haemoptysis. Silent cysts may present as an emergency because of rupture or an allergic reaction. Uncomplicated cysts present as rounded or oval lesions on chest radiography.</li><li>➤ The condition may be silent and found incidentally. Symptomatic patients present with cough, expectoration, fever, chest pain and sometimes haemoptysis.</li><li>➤ Erosion of the bronchioles results in air being introduced between the pericyst and the laminated membrane and gives a fine radiolucent crescent, the ‘meniscus’ or ‘crescent’ sign. This is often regarded as a sign of impending rupture.</li><li>➤ the ‘meniscus’ or ‘crescent’ sign. This is often regarded as a sign of impending rupture.</li><li>➤ When the cyst ruptures, the crumpled collapsed endocyst floats like a lily on the residual fluid, giving rise to the ‘water-lily’ sign on CT scan. Rupture into the pleural cavity results in pleural effusion. CT scan defines the pathology in greater detail.</li><li>➤ The principle of surgery is to preserve as much viable lung tissue as possible. The exact procedure can vary: cystotomy, capitonnage, pericystectomy, segmentectomy or occasionally pneumonectomy</li><li>➤ Ref: Bailey and Love, 28 th Ed. Pg 76</li><li>➤ Ref:</li><li>➤ Bailey and Love, 28 th Ed. Pg 76</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is not a component of MELD score?", "options": [{"label": "A", "text": "Bilirubin", "correct": false}, {"label": "B", "text": "Creatinine", "correct": false}, {"label": "C", "text": "A:G ratio", "correct": true}, {"label": "D", "text": "INR", "correct": false}], "correct_answer": "C. A:G ratio", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) A: G ratio</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Bilirubin. Serum bilirubin levels are a key component of the MELD score. They reflect the liver's ability to conjugate and excrete bilirubin , with higher levels indicating more significant liver dysfunction.</li><li>• Option A: Bilirubin.</li><li>• component of the MELD score.</li><li>• reflect the liver's ability to conjugate and excrete bilirubin</li><li>• higher levels</li><li>• more significant liver dysfunction.</li><li>• Option B: Creatinine. Serum creatinine levels are included in the MELD score to assess renal function , which can be compromised in patients with end-stage liver disease due to conditions like hepatorenal syndrome.</li><li>• Option B: Creatinine.</li><li>• included in the MELD score</li><li>• assess renal function</li><li>• Option D: INR. The International Normalized Ratio (INR) measures the time it takes for blood to clot and is a critical part of the MELD score. It reflects the liver's ability to synthesize clotting factors, with higher values indicating more severe liver disease.</li><li>• Option D: INR.</li><li>• International Normalized Ratio</li><li>• measures the time it takes for blood to clot</li><li>• critical part of the MELD score.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The MELD score , used to assess the severity of chronic liver disease and prioritize liver transplantation , includes serum bilirubin, serum creatinine, and the INR . The albumin:globulin ratio is not a component of the MELD score .</li><li>➤ MELD score</li><li>➤ assess the severity of chronic liver disease</li><li>➤ prioritize liver transplantation</li><li>➤ serum bilirubin, serum creatinine, and the INR</li><li>➤ albumin:globulin ratio is not a component of the MELD score</li><li>➤ A number of parameters are required to accurately assess the degree of liver dysfunction, enable predictions about a patient’s ability to tolerate surgical or radiological procedures and assess the prognosis following transplantation. Two prognostic models commonly used are the Child–Turcotte–Pugh (CTP) classification and the Model for End-Stage Liver Disease (MELD) score. The MELD score was devised to predict the short-term prognosis following Trans jugular intrahepatic portosystemic stent shunt (TIPSS) but has been adopted to prioritize patients on liver transplant waiting lists. In the MELD model survival probability is calculated based on the patient’s international normalized ratio (INR), serum bilirubin and creatinine. MELD scores correlate with operative mortality: 1% increase for each MELD point up to 20 and a further 2% for each point above 20, with rates considerably higher following emergency presentation.</li><li>➤ A number of parameters are required to accurately assess the degree of liver dysfunction, enable predictions about a patient’s ability to tolerate surgical or radiological procedures and assess the prognosis following transplantation.</li><li>➤ Two prognostic models commonly used are the Child–Turcotte–Pugh (CTP) classification and the Model for End-Stage Liver Disease (MELD) score.</li><li>➤ The MELD score was devised to predict the short-term prognosis following Trans jugular intrahepatic portosystemic stent shunt (TIPSS) but has been adopted to prioritize patients on liver transplant waiting lists. In the MELD model survival probability is calculated based on the patient’s international normalized ratio (INR), serum bilirubin and creatinine.</li><li>➤ MELD scores correlate with operative mortality: 1% increase for each MELD point up to 20 and a further 2% for each point above 20, with rates considerably higher following emergency presentation.</li><li>➤ MELD-Na score: Meld + Serum Na levels.</li><li>➤ MELD-Na score: Meld + Serum Na levels.</li><li>➤ MELD 3.0 score: Age and gender are included.</li><li>➤ MELD 3.0 score: Age and gender are included.</li><li>➤ Ref: Bailey 28 th Ed. Pg 1196</li><li>➤ Ref:</li><li>➤ Bailey 28 th Ed. Pg 1196</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All are contra-indications to onco-surgical resection of HCC (Hepatocellular carcinoma) except:", "options": [{"label": "A", "text": "Bilobar tumors", "correct": false}, {"label": "B", "text": "Hepatic vein invasion", "correct": true}, {"label": "C", "text": "Infiltration of CHD", "correct": false}, {"label": "D", "text": "Portal Vein invasion", "correct": false}], "correct_answer": "B. Hepatic vein invasion", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Hepatic vein invasion</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Bilobar Tumors. Bilobar tumors, which are present in both lobes of the liver , are generally considered a contraindication for resection due to the difficulty in completely removing all tumor tissue and the higher risk of postoperative liver failure.</li><li>• Option A: Bilobar Tumors.</li><li>• present in both lobes of the liver</li><li>• considered a contraindication for resection</li><li>• difficulty in completely removing all tumor tissue</li><li>• Option C: Infiltration of CHD (Common Hepatic Duct). Infiltration of the common hepatic duct is typically a contraindication to resection because it indicates advanced disease and increases the complexity of the surgery , which often results in a poor prognosis.</li><li>• Option C: Infiltration of CHD (Common Hepatic Duct).</li><li>• common hepatic duct</li><li>• contraindication to resection</li><li>• indicates advanced disease and increases the complexity of the surgery</li><li>• Option D: PV Invasion (Portal Vein Invasion). Portal vein invasion is also generally considered a contraindication for resection due to the high risk of intrahepatic metastases and the challenges associated with removing all cancerous tissue.</li><li>• Option D: PV Invasion (Portal Vein Invasion).</li><li>• generally considered a contraindication for resection</li><li>• high risk of intrahepatic metastases</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ While the presence of extrahepatic metastasis , multiple or bilobar tumors , and invasion of the common hepatic duct or portal vein are contraindications to the surgical resection of HCC , hepatic vein invasion may not preclude surgery in certain cases, depending on the extent of disease and surgical expertise.</li><li>➤ presence of extrahepatic metastasis</li><li>➤ multiple or bilobar tumors</li><li>➤ invasion of the common hepatic duct</li><li>➤ portal vein</li><li>➤ contraindications to the surgical resection of HCC</li><li>➤ hepatic vein invasion</li><li>➤ Contra-indications to resection of liver tumors</li><li>➤ Contra-indications to resection of liver tumors</li><li>➤ Extra-hepatic metastasis Multiple and bilobar tumors PV/IVC invasion Invasion of CHD</li><li>➤ Extra-hepatic metastasis</li><li>➤ Multiple and bilobar tumors</li><li>➤ PV/IVC invasion</li><li>➤ Invasion of CHD</li><li>➤ Multinodular lesions may represent multiple discrete lesions occurring independently against a background of procarcinogenic parenchymal damage or aggressive tumor biology with intrahepatic metastases. Oncological contraindications include extrahepatic metastasis, multiple/bilobar tumors, main bile duct involvement and tumor thrombus in the main portal vein/inferior vena cava</li><li>➤ Multinodular lesions may represent multiple discrete lesions occurring independently against a background of procarcinogenic parenchymal damage or aggressive tumor biology with intrahepatic metastases.</li><li>➤ Oncological contraindications include extrahepatic metastasis, multiple/bilobar tumors, main bile duct involvement and tumor thrombus in the main portal vein/inferior vena cava</li><li>➤ Ref: Bailey 28 th Ed. Pg 1214</li><li>➤ Ref:</li><li>➤ Bailey 28 th Ed. Pg 1214</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In extended left hemi-hepatectomy, the liver segments resected are:", "options": [{"label": "A", "text": "2,3,4", "correct": false}, {"label": "B", "text": "2,3,4,5,6", "correct": false}, {"label": "C", "text": "2,3,4,5,8", "correct": true}, {"label": "D", "text": "1,2,3,4,5", "correct": false}], "correct_answer": "C. 2,3,4,5,8", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture16.jpg"], "explanation": "<p><strong>Ans. C. 2, 3,4,5,8</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Liver resections and segments removed</li><li>• Liver resections and segments removed</li><li>• Left hemihepatectomy= 2, 3, 4 Right hemihepatectomy= 5,6,7,8 Extended right hemihepatectomy/ right trisectionectomy= 4 and 5,6,7,8 Extended left hemihepatectomy/ left trisectionectomy=2,3,4 and 5,8 Left lateral hepatectomy= 2 and 3</li><li>• Left hemihepatectomy= 2, 3, 4</li><li>• Right hemihepatectomy= 5,6,7,8</li><li>• Extended right hemihepatectomy/ right trisectionectomy= 4 and 5,6,7,8</li><li>• Extended left hemihepatectomy/ left trisectionectomy=2,3,4 and 5,8</li><li>• Left lateral hepatectomy= 2 and 3</li><li>• Ref: Bailey 28 th Ed. Pg 1211</li><li>• Ref:</li><li>• Bailey 28 th Ed. Pg 1211</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is incorrect about management of hepatoma?", "options": [{"label": "A", "text": "Milan criteria is applicable for single tumor up to 5 cm or three tumors each less than 3 cm", "correct": false}, {"label": "B", "text": "A FLR (future liver remnant) of at least 40% normal liver is a pre-requisite for resection", "correct": true}, {"label": "C", "text": "Colorectal metastasis to liver can be excised", "correct": false}, {"label": "D", "text": "Percutaneous ablation is used for hepatomas", "correct": false}], "correct_answer": "B. A FLR (future liver remnant) of at least 40% normal liver is a pre-requisite for resection", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) A FLR (Future liver remnant) of at least 40% normal liver is a pre-requisite for resection.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Milan Criteria. The Milan criteria are indeed applicable for liver transplantation in patients with HCC , specifying that eligible patients should have a single tumor up to 5 cm or up to three tumors, each less than 3 cm. This statement is correct.</li><li>• Option A: Milan Criteria.</li><li>• indeed applicable for liver transplantation in patients with HCC</li><li>• Option C: Colorectal Metastasis to Liver. It is true that colorectal metastases to the liver can be excised in certain circumstances. Liver resection can be part of the treatment for selected patients with metastatic colorectal cancer to the liver, particularly if it is liver-only disease.</li><li>• Option C: Colorectal Metastasis to Liver.</li><li>• true</li><li>• colorectal metastases to the liver can be excised in certain circumstances.</li><li>• Option D: Percutaneous Ablation. Percutaneous ablation, including radiofrequency ablation (RFA) and other techniques , is a treatment option for hepatomas, especially for patients with small, localized tumors who are not candidates for surgery.</li><li>• Option D: Percutaneous Ablation.</li><li>• radiofrequency ablation</li><li>• other techniques</li><li>• treatment option for hepatomas,</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ For the management of hepatoma , the Milan criteria guide liver transplantation eligibility, percutaneous ablation is a treatment option for localized tumors , colorectal metastasis to the liver may be resected in selected patients , and the requirement for future liver remnant volume must be individualized, particularly considering the presence of underlying liver disease.</li><li>➤ management of hepatoma</li><li>➤ Milan criteria guide liver transplantation eligibility, percutaneous ablation</li><li>➤ treatment option for localized tumors</li><li>➤ colorectal metastasis</li><li>➤ liver may be resected in selected patients</li><li>➤ There is no clear consensus about the volume required for adequate postresection liver function but an FLR/TELV ratio of at least 25% is recommended with a normal liver and 40% in the presence of cirrhosis. Ablation techniques now include RFA, microwave ablation, cryoablation, laser ablation, irreversible electroporation (IRE) and alcohol injection, all of which can be performed percutaneously, laparoscopically or at open surgery. Patients with small-volume resectable lesions who are not sufficiently fit to undergo liver resection should be considered for ablation, as should those with liver metastases were predicted FLR precludes resection. Liver transplantation that definitively treats the tumour and underlying cirrhosis represents an attractive option. Transplantation for HCC, first described by Mazzaferro in 1996 for patients with tumours ≤5 cm or up to three nodules ≤3 cm, achieved 4-year overall survivals of 75% and recurrence-free survivals of 83%. These inclusion criteria were adopted as the Milan criteria , with angioinvasion and extrahepatic involvement as additional exclusion criteria, and are now universally accepted. Up to 70% of patients with CRC develop synchronous (15–25%) or metachronous (20–45%) liver metastases. Liver resection in selected patients with liver-only metastatic disease demonstrated 5-year survivals of 50%, so the potential benefits were recognised. Despite recent advances in chemotherapeutic agents, resection remains the only potentially curative option, but only 20% of patients will be candidates at presentation.</li><li>➤ There is no clear consensus about the volume required for adequate postresection liver function but an FLR/TELV ratio of at least 25% is recommended with a normal liver and 40% in the presence of cirrhosis.</li><li>➤ at least 25% is recommended with a normal liver and 40% in the presence of cirrhosis.</li><li>➤ Ablation techniques now include RFA, microwave ablation, cryoablation, laser ablation, irreversible electroporation (IRE) and alcohol injection, all of which can be performed percutaneously, laparoscopically or at open surgery.</li><li>➤ Patients with small-volume resectable lesions who are not sufficiently fit to undergo liver resection should be considered for ablation, as should those with liver metastases were predicted FLR precludes resection.</li><li>➤ Liver transplantation that definitively treats the tumour and underlying cirrhosis represents an attractive option. Transplantation for HCC, first described by Mazzaferro in 1996 for patients with tumours ≤5 cm or up to three nodules ≤3 cm, achieved 4-year overall survivals of 75% and recurrence-free survivals of 83%. These inclusion criteria were adopted as the Milan criteria , with angioinvasion and extrahepatic involvement as additional exclusion criteria, and are now universally accepted.</li><li>➤ Milan criteria</li><li>➤ Up to 70% of patients with CRC develop synchronous (15–25%) or metachronous (20–45%) liver metastases. Liver resection in selected patients with liver-only metastatic disease demonstrated 5-year survivals of 50%, so the potential benefits were recognised. Despite recent advances in chemotherapeutic agents, resection remains the only potentially curative option, but only 20% of patients will be candidates at presentation.</li><li>➤ Ref: Bailey 28 th Ed. Pg 1212, 1216.</li><li>➤ Ref: Bailey 28 th Ed. Pg 1212, 1216.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is not a boundary of the ‘hepato-cystic’ triangle?", "options": [{"label": "A", "text": "Common hepatic duct", "correct": false}, {"label": "B", "text": "Cystic duct", "correct": false}, {"label": "C", "text": "Cystic artery", "correct": true}, {"label": "D", "text": "Inferior surface of liver", "correct": false}], "correct_answer": "C. Cystic artery", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture18.jpg"], "explanation": "<p><strong>Ans. C. Cystic artery</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Common Hepatic Duct. This is one of the borders of the hepatocystic triangle , running medially.</li><li>• Option A: Common Hepatic Duct.</li><li>• one of the borders of the hepatocystic triangle</li><li>• Option B: Cystic Duct. The cystic duct forms the lateral border of the triangle and is a critical structure to identify during gallbladder surgery to avoid damage to the common bile duct.</li><li>• Option B: Cystic Duct.</li><li>• cystic duct forms the lateral border of the triangle</li><li>• critical structure to identify during gallbladder surgery</li><li>• Option D: Inferior Surface of Liver. The superior border of Calot's triangle is traditionally defined by the liver's inferior surface , specifically the liver bed from which the gallbladder is removed.</li><li>• Option D: Inferior Surface of Liver.</li><li>• superior border of Calot's triangle</li><li>• liver's inferior surface</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The hepatocystic triangle, an important landmark in gallbladder surgery , is bordered by the common hepatic duct medially , the cystic duct laterally, and the inferior surface of the liver superiorly . The cystic artery, while commonly found within this triangle, is not one of its anatomical borders.</li><li>➤ hepatocystic triangle,</li><li>➤ landmark in gallbladder surgery</li><li>➤ bordered by the common hepatic duct medially</li><li>➤ cystic duct laterally,</li><li>➤ inferior surface of the liver superiorly</li><li>➤ Calot’s triangle, or the hepatobiliary triangle , is the spaces bordered by the cystic duct inferiorly, the common hepatic duct medially and the superior border of the cystic artery. The Calots triangle has been modified in contemporary literature as the area bound superiorly by the inferior surface of the liver, laterally by the cystic duct and the medial border of the gallbladder and medially by the common hepatic duct (‘hepatocystic triangle’). It is an important surgical landmark as the cystic artery usually can be found within its boundaries.</li><li>➤ Calot’s triangle, or the hepatobiliary triangle , is the spaces bordered by the cystic duct inferiorly, the common hepatic duct medially and the superior border of the cystic artery.</li><li>➤ Calot’s triangle, or the hepatobiliary triangle</li><li>➤ The Calots triangle has been modified in contemporary literature as the area bound superiorly by the inferior surface of the liver, laterally by the cystic duct and the medial border of the gallbladder and medially by the common hepatic duct (‘hepatocystic triangle’). It is an important surgical landmark as the cystic artery usually can be found within its boundaries.</li><li>➤ modified</li><li>➤ Ref: Bailey 28 th Ed. Pg 1232</li><li>➤ Ref:</li><li>➤ Bailey 28 th Ed. Pg 1232</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All are risk factors for the development of cholesterol gallstones except?", "options": [{"label": "A", "text": "Obesity", "correct": false}, {"label": "B", "text": "Short bowel syndrome", "correct": false}, {"label": "C", "text": "Oral contraceptives", "correct": false}, {"label": "D", "text": "Hereditary spherocytosis", "correct": true}], "correct_answer": "D. Hereditary spherocytosis", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Hereditary spherocytosis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Obesity. Obesity is a well-known risk factor for the development of cholesterol gallstones. It is associated with increased cholesterol synthesis, which can lead to supersaturation of bile with cholesterol.</li><li>• Option A: Obesity.</li><li>• risk factor for the development of cholesterol gallstones.</li><li>• Option B: Short Bowel Syndrome. Short bowel syndrome can lead to a decrease in the bile salt pool due to the reduced reabsorption area in the ileum , contributing to cholesterol gallstone formation.</li><li>• Option B: Short Bowel Syndrome.</li><li>• decrease in the bile salt pool due to the reduced reabsorption area in the ileum</li><li>• Option C: Oral Contraceptives. The use of oral contraceptives has been associated with an increased risk of cholesterol gallstones because they can increase biliary cholesterol saturation and reduce gallbladder motility.</li><li>• Option C: Oral Contraceptives.</li><li>• associated with an increased risk of cholesterol gallstones</li><li>• increase biliary cholesterol saturation</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Hereditary spherocytosis is a risk factor for the formation of pigment gallstones , not cholesterol gallstones , due to its association with hemolysis and increased bilirubin turnover. In contrast, factors such as obesity, short bowel syndrome, and the use of oral contraceptives can contribute to the development of cholesterol gallstones by altering the composition and concentration of bile components.</li><li>➤ Hereditary spherocytosis</li><li>➤ risk factor for the formation of pigment gallstones</li><li>➤ not cholesterol gallstones</li><li>➤ association with hemolysis</li><li>➤ increased bilirubin turnover.</li><li>➤ Bile = cholesterol + bile salts + lecithin + dissolved in water</li><li>➤ Bile = cholesterol + bile salts + lecithin + dissolved in water</li><li>➤ Change in concentration of bile components will lead to stone formation.</li><li>➤ Cholesterol stones:</li><li>➤ Cholesterol stones:</li><li>➤ Increase in cholesterol d/t-obesity.</li><li>➤ Increase in cholesterol d/t-obesity.</li><li>➤ High fat diet/dyslipidemia</li><li>➤ High fat diet/dyslipidemia</li><li>➤ Bile salts pool decreases d/t -terminal ileal resection/short bowel syndrome/crash diets.</li><li>➤ Bile salts pool decreases d/t -terminal ileal resection/short bowel syndrome/crash diets.</li><li>➤ Bariatric surgery</li><li>➤ Bariatric surgery</li><li>➤ Pigment stones:</li><li>➤ Pigment stones:</li><li>➤ Black pigment –hemolytic disorders Brown pigment- biliary tract infection (worms)</li><li>➤ Black pigment –hemolytic disorders</li><li>➤ Brown pigment- biliary tract infection (worms)</li><li>➤ Ref: Bailey 28 th Ed. Pg 1243</li><li>➤ Ref:</li><li>➤ Bailey 28 th Ed. Pg 1243</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "According to Tokyo Consensus guidelines for severity of acute cholecystitis, which of the following is a part of grade 2 cholecystitis?", "options": [{"label": "A", "text": "Gangrenous cholecystitis", "correct": true}, {"label": "B", "text": "Cardiovascular dysfunction", "correct": false}, {"label": "C", "text": "Gall bladder inflammation with no organ dysfunction", "correct": false}, {"label": "D", "text": "Decreased levels of consciousness", "correct": false}], "correct_answer": "A. Gangrenous cholecystitis", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/screenshot-2024-03-28-181901.jpg"], "explanation": "<p><strong>Ans. A. Gangrenous cholecystitis</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old female patient presented to the OPD with complaints of pain in the right upper quadrant for 5 days. On palpation, there is tenderness in the right hypochondrium, and the pain was referred to the tip of the right shoulder. What is the investigation of choice in this case?", "options": [{"label": "A", "text": "CECT abdomen", "correct": false}, {"label": "B", "text": "ERCP", "correct": false}, {"label": "C", "text": "EUS", "correct": false}, {"label": "D", "text": "USG", "correct": true}], "correct_answer": "D. USG", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) USG</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: CECT Abdomen. While Contrast-Enhanced Computed Tomography (CECT) of the abdomen can provide detailed images and is useful for diagnosing a range of abdominal conditions , it is not the first-line investigation for suspected acute cholecystitis.</li><li>• Option A: CECT Abdomen.</li><li>• Contrast-Enhanced Computed Tomography</li><li>• abdomen</li><li>• provide detailed images</li><li>• useful for diagnosing a range of abdominal conditions</li><li>• Option B: ERCP. Endoscopic Retrograde Cholangiopancreatography (ERCP) is an invasive procedure typically used to identify and treat bile duct stones and not a first-line diagnostic tool for acute cholecystitis.</li><li>• Option B: ERCP. Endoscopic Retrograde Cholangiopancreatography</li><li>• invasive procedure</li><li>• used to identify and treat bile duct stones</li><li>• Option C: EUS. Endoscopic Ultrasound (EUS) can provide high-resolution images of the biliary tree and surrounding organs and is helpful in diagnosing gallstones , but it is more invasive than ultrasound and not typically the first choice.</li><li>• Option C: EUS. Endoscopic Ultrasound</li><li>• high-resolution images</li><li>• biliary tree and surrounding organs</li><li>• diagnosing gallstones</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The investigation of choice for a patient presenting with symptoms suggestive of acute cholecystitis , characterized by right upper quadrant pain and referred pain to the right shoulder , is abdominal ultrasonography (USG). It is highly sensitive for detecting gallbladder wall thickening , pericholecystic fluid , and the presence of gallstones , and it can elicit an ultrasonographic Murphy’s sign .</li><li>➤ acute cholecystitis</li><li>➤ right upper quadrant pain</li><li>➤ referred pain to the right shoulder</li><li>➤ abdominal ultrasonography</li><li>➤ highly sensitive for detecting gallbladder wall thickening</li><li>➤ pericholecystic fluid</li><li>➤ presence of gallstones</li><li>➤ ultrasonographic Murphy’s sign</li><li>➤ Transabdominal ultrasonography (USG) is the initial imaging modality of choice as it is accurate, readily available. Acute calculous cholecystitis is diagnosed radiologically (sensitivity 90–95%) by thickening of the gallbladder wall (&gt;3 mm), presence of pericholecystic fluid or direct tenderness when the probe is pushed against the gallbladder (ultrasonographic Murphy’s sign)</li><li>➤ by thickening of the gallbladder wall (&gt;3 mm), presence of pericholecystic fluid or direct tenderness when the probe is pushed against the gallbladder (ultrasonographic Murphy’s sign)</li><li>➤ Ref: Bailey 28 th Ed. Pg 1235 and 1244</li><li>➤ Ref: Bailey 28 th Ed. Pg 1235 and 1244</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the incorrect statement with respect to acute cholecystitis?", "options": [{"label": "A", "text": "In patients with Tokyo class 2 severity, emergency lap cholecystectomy is done.", "correct": false}, {"label": "B", "text": "CECT abdomen is the IOC for acute cholecystitis.", "correct": true}, {"label": "C", "text": "Murphy’s sign is the diagnostic sign for acute cholecystitis.", "correct": false}, {"label": "D", "text": "The GB wall is usually thickened to more than 4 mm on imaging.", "correct": false}], "correct_answer": "B. CECT abdomen is the IOC for acute cholecystitis.", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) CECT abdomen is the IOC for acute cholecystitis.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Tokyo Guidelines for Acute Cholecystitis. Tokyo class 2 severity represents moderate acute cholecystitis . In such cases, if the patient is stable and facilities are available , emergency laparoscopic cholecystectomy is considered. If the patient is too ill, initial conservative treatment followed by delayed surgery is often chosen.</li><li>• Option A:</li><li>• Tokyo Guidelines for Acute Cholecystitis.</li><li>• Tokyo class 2 severity</li><li>• moderate acute cholecystitis</li><li>• patient is stable and facilities are available</li><li>• emergency laparoscopic cholecystectomy</li><li>• Option C: Murphy’s Sign. Murphy’s sign is elicited by palpating the right upper quadrant of the abdomen and asking the patient to take a deep breath. Increased pain with inspiration when the inflamed gallbladder comes into contact with the examiner's hand is a positive Murphy's sign and suggests acute cholecystitis.</li><li>• Option C:</li><li>• Murphy’s Sign.</li><li>• elicited by palpating the right upper quadrant of the abdomen</li><li>• Option D: Gallbladder Wall Thickness. In acute cholecystitis , the gallbladder wall is typically thickened to more than 3 mm on imaging.</li><li>• Option D:</li><li>• Gallbladder Wall Thickness.</li><li>• acute cholecystitis</li><li>• gallbladder wall</li><li>• thickened to more than 3 mm</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The correct diagnosis and management of acute cholecystitis rely on clinical examination, laboratory findings , and appropriate imaging , with ultrasonography being the first-line imaging choice . Severity assessment based on the Tokyo Guidelines helps in deciding the timing and approach for cholecystectomy, with emergency surgery being a consideration for moderate cases where facilities are adequate, and the patient is fit for surgery.</li><li>➤ acute cholecystitis rely</li><li>➤ clinical examination, laboratory findings</li><li>➤ appropriate imaging</li><li>➤ ultrasonography</li><li>➤ first-line imaging choice</li><li>➤ USG ABDOMEN</li><li>➤ USG ABDOMEN</li><li>➤ Gallstones : Posterior acoustic shadow/ moves on changing position Acute calculous cholecystitis : gallstones + thickening of GB wall (&gt;4mm) / free fluid or edema around gallbladder</li><li>➤ Gallstones : Posterior acoustic shadow/ moves on changing position</li><li>➤ Gallstones</li><li>➤ Acute calculous cholecystitis : gallstones + thickening of GB wall (&gt;4mm) / free fluid or edema around gallbladder</li><li>➤ Acute calculous cholecystitis</li><li>➤ Management of Acute cholecystitis: 1st stabilize the patient + iv antibiotics.</li><li>➤ Management of Acute cholecystitis: 1st stabilize the patient + iv antibiotics.</li><li>➤ Timing of cholecystectomy depends on severity.</li><li>➤ Timing of cholecystectomy depends on severity.</li><li>➤ Tokyo 1: mild: early cholecystectomy (within 5 to 7 days)</li><li>➤ Tokyo 2: moderate: good available Facilities: emergency lap. Cholecystectomy</li><li>➤ Tokyo 3: severe: low urine output, deranged LFT, hypoxic, encephalopathy</li><li>➤ Here,</li><li>➤ If facilities available + patient can withstand surgery: Emergency cholecystectomy. If patient too sick initially do lap cholecystectomy: percutaneous cholecystostomy followed by interval cholecystectomy. HIDA scan : Non-visualization of the gallbladder is suggestive of acute cholecystitis. If the patient has a contracted gallbladder, as often occurs in chronic cholecystitis, visualisation may be reduced or delayed. An abnormally low gallbladder ejection fraction may be suggestive of gallbladder dyskinesia.</li><li>➤ If facilities available + patient can withstand surgery: Emergency cholecystectomy.</li><li>➤ If patient too sick initially do lap cholecystectomy: percutaneous cholecystostomy followed by interval cholecystectomy.</li><li>➤ HIDA scan : Non-visualization of the gallbladder is suggestive of acute cholecystitis. If the patient has a contracted gallbladder, as often occurs in chronic cholecystitis, visualisation may be reduced or delayed. An abnormally low gallbladder ejection fraction may be suggestive of gallbladder dyskinesia.</li><li>➤ HIDA scan</li><li>➤ Ref : Bailey 28 th Ed. PG 1235-36</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. PG 1235-36</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the false statement with respect to xantho-granulomatous cholecystitis?", "options": [{"label": "A", "text": "More common in females", "correct": false}, {"label": "B", "text": "Most likely caused by rupture of Rokitansky-Aschoff sinuses", "correct": false}, {"label": "C", "text": "Diagnosed on purely clinical basis", "correct": true}, {"label": "D", "text": "Cholecystectomy is the treatment of choice", "correct": false}], "correct_answer": "C. Diagnosed on purely clinical basis", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Diagnosed on purely clinical basis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. More common in females : Xanthogranulomatous cholecystitis has a higher incidence in females , which aligns with the general demographic pattern for gallbladder diseases.</li><li>• Option A. More common in females</li><li>• Xanthogranulomatous cholecystitis</li><li>• higher incidence in females</li><li>• Option B. Most likely caused by rupture of Rokitansky-Aschoff sinuses : This condition can be caused by the rupture of these sinuses , leading to bile leakage and a resultant inflammatory response with the formation of xanthoma cells .</li><li>• Option B.</li><li>• Most likely caused by rupture of Rokitansky-Aschoff sinuses</li><li>• caused by the rupture of these sinuses</li><li>• bile leakage</li><li>• resultant inflammatory response</li><li>• formation of xanthoma cells</li><li>• Option D. Cholecystectomy is the treatment of choice : The definitive treatment for xanthogranulomatous cholecystitis is surgical removal of the gallbladder because this condition can mimic gallbladder cancer and is typically not responsive to conservative management.</li><li>• Option D.</li><li>• Cholecystectomy is the treatment of choice</li><li>• definitive treatment</li><li>• surgical removal of the gallbladder</li><li>• mimic gallbladder cancer</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ The diagnosis of xanthogranulomatous cholecystitis is not based solely on clinical presentation but requires imaging and histopathological analysis , with cholecystectomy being the treatment of choice due to the condition's potential to mimic malignancy and lack of response to medical therapy.</li><li>➤ diagnosis of xanthogranulomatous cholecystitis</li><li>➤ not based solely on clinical presentation</li><li>➤ imaging and histopathological analysis</li><li>➤ cholecystectomy</li><li>➤ treatment of choice due to the condition's potential to mimic malignancy</li><li>➤ Xantho-granulomatous cholecystitis is an uncommon inflammation of the gallbladder, more frequently seen in India and Japan. It is more common in females. It is caused by extravasation of bile into the gallbladder wall from rupture of the Rokitansky–Aschoff sinuses or by mucosal ulceration as a result of a focal or diffuse destructive inflammatory process, with accumulation of lipid-laden macrophages (xanthoma cells), fibrous tissue and acute and chronic inflammatory cells. USG shows gallbladder wall thickening (diffuse or focal, with intact mucosal lining), intramural hypoechoic nodules or bands and often the presence of gallstones. CT shows 5- to 20-mm intramural hypo attenuating nodules and poor/heterogeneous contrast enhancement. As with acute cholecystitis, early enhancement of the adjacent liver parenchyma may occur. Extension into the liver along with enlarged hepatoduodenal lymph nodes closely mimics gallbladder carcinoma. Diagnosis is difficult and depends on pathological examination. Intraoperatively, frozen-section examination should be carried out to differentiate xantho-granulomatous cholecystitis from carcinoma of the gallbladder (coexistence of gallbladder cancer 2.3–13.3%). Because of diagnostic difficulties if there is preoperative suspicion of xantho-granulomatous cholecystitis open cholecystectomy should be considered.</li><li>➤ Xantho-granulomatous cholecystitis is an uncommon inflammation of the gallbladder, more frequently seen in India and Japan. It is more common in females.</li><li>➤ It is caused by extravasation of bile into the gallbladder wall from rupture of the Rokitansky–Aschoff sinuses or by mucosal ulceration as a result of a focal or diffuse destructive inflammatory process, with accumulation of lipid-laden macrophages (xanthoma cells), fibrous tissue and acute and chronic inflammatory cells.</li><li>➤ USG shows gallbladder wall thickening (diffuse or focal, with intact mucosal lining), intramural hypoechoic nodules or bands and often the presence of gallstones.</li><li>➤ CT shows 5- to 20-mm intramural hypo attenuating nodules and poor/heterogeneous contrast enhancement. As with acute cholecystitis, early enhancement of the adjacent liver parenchyma may occur. Extension into the liver along with enlarged hepatoduodenal lymph nodes closely mimics gallbladder carcinoma.</li><li>➤ Diagnosis is difficult and depends on pathological examination. Intraoperatively, frozen-section examination should be carried out to differentiate xantho-granulomatous cholecystitis from carcinoma of the gallbladder (coexistence of gallbladder cancer 2.3–13.3%).</li><li>➤ Because of diagnostic difficulties if there is preoperative suspicion of xantho-granulomatous cholecystitis open cholecystectomy should be considered.</li><li>➤ Ref: Bailey 28 th Ed. Pg 1247.</li><li>➤ Ref:</li><li>➤ Bailey 28 th Ed. Pg 1247.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following parts is not usually removed in radical cholecystectomy?", "options": [{"label": "A", "text": "Segment IVb of liver", "correct": false}, {"label": "B", "text": "Segment V of liver", "correct": false}, {"label": "C", "text": "Portal vein", "correct": true}, {"label": "D", "text": "Peri choledochal lymph node", "correct": false}], "correct_answer": "C. Portal vein", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Portal vein</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ In radical cholecystectomy , the gallbladder, adjacent liver tissue (segments IVb and V), and regional lymph nodes are removed to treat gallbladder cancer ; however, the portal vein is preserved unless directly involved by the tumor due to its critical role in hepatic blood flow .</li><li>➤ radical cholecystectomy</li><li>➤ gallbladder, adjacent liver tissue</li><li>➤ regional lymph nodes are removed</li><li>➤ treat gallbladder cancer</li><li>➤ portal vein is preserved unless directly involved by the tumor</li><li>➤ hepatic blood flow</li><li>➤ Ref: Bailey 28 th Ed. Pg 1259</li><li>➤ Ref: Bailey 28 th Ed. Pg 1259</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "How many sphincters comprise the sphincter of Oddi complex?", "options": [{"label": "A", "text": "2", "correct": false}, {"label": "B", "text": "3", "correct": false}, {"label": "C", "text": "4", "correct": true}, {"label": "D", "text": "5", "correct": false}], "correct_answer": "C. 4", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture25.jpg"], "explanation": "<p><strong>Ans. C) 4</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• The Sphincter of Oddi comprises of 4 parts:</li><li>• Sphincter of Oddi</li><li>• 4 parts:</li><li>• Ampullary Pancreatic Superior choledochal Inferior choledochal</li><li>• Ampullary</li><li>• Pancreatic</li><li>• Superior choledochal</li><li>• Inferior choledochal</li><li>• Ref: Bailey and Love 28 th Ed. Pg 1262 Fig. 72.5</li><li>• Ref: Bailey and Love 28 th Ed. Pg 1262 Fig. 72.5</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 7-year-old girl from Bihar presented with pain in the right upper quadrant. A lump is palpated in the right hypochondriac region of the abdomen. Investigation revealed conjugated hyper-bilirubinemia. USG abdomen showed dilated CBD of 6 mm. What will be your next investigation?", "options": [{"label": "A", "text": "Liver biopsy", "correct": false}, {"label": "B", "text": "MRCP", "correct": true}, {"label": "C", "text": "ERCP", "correct": false}, {"label": "D", "text": "HIDA", "correct": false}], "correct_answer": "B. MRCP", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) MRCP</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Liver biopsy - This is an invasive procedure typically used to diagnose liver tissue diseases and is not the first line of investigation for suspected choledochal cysts.</li><li>• Option A:</li><li>• Liver biopsy</li><li>• invasive procedure</li><li>• diagnose liver tissue diseases</li><li>• not the first line of investigation</li><li>• Option C: ERCP (Endoscopic Retrograde Cholangiopancreatography) - This is a more invasive procedure compared to MRCP and is often used therapeutically in biliary diseases , although it can also provide diagnostic information.</li><li>• Option C:</li><li>• ERCP (Endoscopic Retrograde Cholangiopancreatography)</li><li>• more invasive procedure compared to MRCP</li><li>• therapeutically in biliary diseases</li><li>• Option D: HIDA (Hepatobiliary Iminodiacetic Acid) scan - This nuclear medicine test assesses the function of the liver and biliary system but is not typically used for the initial investigation of choledochal cysts.</li><li>• Option D:</li><li>• HIDA (Hepatobiliary Iminodiacetic Acid) scan</li><li>• nuclear medicine test assesses the function of the liver</li><li>• biliary system</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ In a patient with clinical signs suggestive of a choledochal cyst , such as RUQ pain , palpable lump , and conjugated hyperbilirubinemia , the investigation of choice is MRCP . This non-invasive imaging technique provides a clear anatomical delineation of the biliary tree , which is essential for diagnosis and surgical planning.</li><li>➤ choledochal cyst</li><li>➤ RUQ pain</li><li>➤ palpable lump</li><li>➤ conjugated hyperbilirubinemia</li><li>➤ investigation of choice is MRCP</li><li>➤ non-invasive imaging technique</li><li>➤ clear anatomical delineation of the biliary tree</li><li>➤ essential for diagnosis and surgical planning.</li><li>➤ Choledochal cysts are congenital dilatations of the intra- and/ or extrahepatic biliary system. Patients may present at any age with jaundice, fever, abdominal pain and a right upper quadrant mass on examination; 60% of cases are diagnosed before the age of 10 years. Pancreatitis is not an infrequent presentation in adults. Patients with choledochal cysts have an increased risk of developing cholangiocarcinoma. MRCP will reveal the anatomy, in particular the relationship between the lower end of the bile duct and the pancreatic duct. Radical excision of the cyst is the treatment of choice, with reconstruction of the biliary tract using a Roux-en-Y loop of jejunum. Complete resection is important because of an association with the later development of cholangiocarcinoma.</li><li>➤ Choledochal cysts are congenital dilatations of the intra- and/ or extrahepatic biliary system.</li><li>➤ Patients may present at any age with jaundice, fever, abdominal pain and a right upper quadrant mass on examination; 60% of cases are diagnosed before the age of 10 years. Pancreatitis is not an infrequent presentation in adults.</li><li>➤ Patients with choledochal cysts have an increased risk of developing cholangiocarcinoma.</li><li>➤ MRCP will reveal the anatomy, in particular the relationship between the lower end of the bile duct and the pancreatic duct.</li><li>➤ Radical excision of the cyst is the treatment of choice, with reconstruction of the biliary tract using a Roux-en-Y loop of jejunum.</li><li>➤ Complete resection is important because of an association with the later development of cholangiocarcinoma.</li><li>➤ Ref: Bailey and Love 28 th Ed. Pg 1242.</li><li>➤ Ref:</li><li>➤ Bailey and Love 28 th Ed. Pg 1242.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following statements is false regarding choledochal cysts?", "options": [{"label": "A", "text": "Jaundice is the most consistent symptom.", "correct": false}, {"label": "B", "text": "Treatment is resection of the entire cyst and appropriate surgical reconstruction.", "correct": false}, {"label": "C", "text": "Males are affected more commonly than females.", "correct": true}, {"label": "D", "text": "It’s a premalignant condition.", "correct": false}], "correct_answer": "C. Males are affected more commonly than females.", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Males are affected more commonly than females.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Jaundice is the most consistent symptom . Jaundice can be a significant symptom in choledochal cysts due to bile duct obstruction , but it may not always be present in every case, especially if the cyst does not cause obstruction.</li><li>• Option A:</li><li>• Jaundice is the most consistent symptom</li><li>• Jaundice</li><li>• choledochal cysts due to bile duct obstruction</li><li>• Option B: Treatment is resection of the entire cyst and appropriate surgical reconstruction . This is the recommended treatment for choledochal cysts to prevent complications such as cholangiocarcinoma .</li><li>• Option B:</li><li>• Treatment is resection of the entire cyst and appropriate surgical reconstruction</li><li>• recommended treatment for choledochal cysts</li><li>• complications such as cholangiocarcinoma</li><li>• Option D: It’s a premalignant condition - This is true . Choledochal cysts are associated with an increased risk of developing cholangiocarcinoma.</li><li>• Option D:</li><li>• It’s a premalignant condition</li><li>• true</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ Choledochal cysts occur more frequently in females and are considered a premalignant condition , warranting resection of the cyst and surgical reconstruction to prevent malignancy. Jaundice is a common symptom due to bile duct obstruction. The diagnosis and treatment should be tailored to the patient's presentation and cyst type, with the aim to alleviate symptoms and reduce the risk of cancer development.</li><li>➤ Choledochal cysts</li><li>➤ frequently in females</li><li>➤ premalignant condition</li><li>➤ warranting resection of the cyst</li><li>➤ surgical reconstruction to prevent malignancy.</li><li>➤ Choledochal cysts:</li><li>➤ Choledochal cysts:</li><li>➤ It affects females 3-8 times more often than males. The incidence of cholangiocarcinoma in patients with biliary cysts ranges from 10-30%.</li><li>➤ It affects females 3-8 times more often than males.</li><li>➤ The incidence of cholangiocarcinoma in patients with biliary cysts ranges from 10-30%.</li><li>➤ The classic clinical triad of symptoms include abdominal pain, jaundice, and a mass, with jaundice being a consistent finding.</li><li>➤ The classic clinical triad of symptoms include abdominal pain, jaundice, and a mass, with jaundice being a consistent finding.</li><li>➤ Surgical management of choledochal cysts consists of resection of the entire cyst and appropriate surgical reconstruction. For Type III, sphincterotomy is recommended.</li><li>➤ Surgical management of choledochal cysts consists of resection of the entire cyst and appropriate surgical reconstruction.</li><li>➤ For Type III, sphincterotomy is recommended.</li><li>➤ Ref: Bailey and Love 28 th Ed. Pg 1242.</li><li>➤ Ref:</li><li>➤ Bailey and Love 28 th Ed. Pg 1242.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A stricture in the bile duct extending to both the right and left ducts leading to discontinuity is classified in what way under the Bismuth classification?", "options": [{"label": "A", "text": "E2", "correct": false}, {"label": "B", "text": "E3", "correct": false}, {"label": "C", "text": "E4", "correct": true}, {"label": "D", "text": "E5", "correct": false}], "correct_answer": "C. E4", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture28.jpg"], "explanation": "<p><strong>Ans. C) E4</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Strassberg classification of bile duct injuries are divided into acute and chronic . Acute bile duct injuries are classified from A to D and E is divided from E1-E6 , as chronic bile duct injury (stricture).</li><li>• Strassberg classification</li><li>• bile duct injuries</li><li>• acute and chronic</li><li>• Acute bile duct injuries</li><li>• A to D and E is divided from E1-E6</li><li>• chronic bile duct injury</li><li>• Bismuth classification of biliary stricture:</li><li>• Bismuth classification of biliary stricture:</li><li>• E1 - low stricture, away from confluence (&gt; 2 cm away)</li><li>• E2 - near confluence (within 2 cm)</li><li>• E3 - at confluence, both ducts are in continuity</li><li>• E4 - involving right and left ducts</li><li>• E5 - stricture of right posterior duct (late complication of Strassberg B) + common hepatic duct</li><li>• Ref: Bailey 28 th Edition Pg 1252</li><li>• Ref: Bailey 28 th Edition Pg 1252</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old female who underwent a lap cholecystectomy one year back presented back to the clinic with features of obstructive jaundice. MRCP shows a stricture in the common hepatic duct 2 cm from confluence. What will be your treatment of choice in the above condition?", "options": [{"label": "A", "text": "ERCP + stenting", "correct": false}, {"label": "B", "text": "Percutaneous trans hepatic biliary drainage (PTBD)", "correct": false}, {"label": "C", "text": "Hepaticojejunostomy", "correct": true}, {"label": "D", "text": "Conservative management", "correct": false}], "correct_answer": "C. Hepaticojejunostomy", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture29.jpg"], "explanation": "<p><strong>Ans. C) Hepaticojejunostomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: ERCP + stenting - This is a less invasive option for treating bile duct strictures , where an endoscope is used to place a stent in the bile duct to keep it open, but it is typically used for distal bile duct strictures.</li><li>• Option A:</li><li>• ERCP + stenting</li><li>• less invasive</li><li>• treating bile duct strictures</li><li>• endoscope is used to place a stent in the bile duct</li><li>• Option B: Percutaneous transhepatic biliary drainage (PTBD) - PTBD is an interventional radiology procedure where an external drain is placed in the bile duct , usually as a temporary measure before definitive surgery, or if surgery is not possible.</li><li>• Option B:</li><li>• Percutaneous transhepatic biliary drainage (PTBD)</li><li>• interventional radiology procedure</li><li>• external drain is placed in the bile duct</li><li>• Option D: Conservative management - This is usually not an option for symptomatic bile duct strictures as it does not address the underlying obstruction.</li><li>• Option D:</li><li>• Conservative management</li><li>• not an option for symptomatic bile duct strictures</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ In a patient presenting with obstructive jaundice due to a common hepatic duct stricture post-cholecystectomy , the preferred treatment is a Roux-en-Y hepaticojejunostomy performed by an experienced hepatobiliary surgeon . This surgical approach is indicated for high-level strictures or transections that cannot be managed with less invasive endoscopic techniques.</li><li>➤ obstructive jaundice due to a common hepatic duct stricture post-cholecystectomy</li><li>➤ Roux-en-Y hepaticojejunostomy</li><li>➤ hepatobiliary surgeon</li><li>➤ high-level strictures</li><li>➤ transections that cannot be managed with less invasive endoscopic techniques.</li><li>➤ For benign stricture or duct transection, the preferred treatment is a Roux-en-Y hepatico-jejunostomy performed by an experienced hepatobiliary surgeon. For a stricture of recent onset through which a guidewire can be passed, balloon dilatation with insertion of a stent is an acceptable option, provided the services of an experienced endoscopist are available. Biliary reconstruction in the presence of peritonitis, combined vascular and bile duct injuries and injury at or above the level of the biliary bifurcation are significant predictors of poor surgical outcome.</li><li>➤ For benign stricture or duct transection, the preferred treatment is a Roux-en-Y hepatico-jejunostomy performed by an experienced hepatobiliary surgeon.</li><li>➤ For a stricture of recent onset through which a guidewire can be passed, balloon dilatation with insertion of a stent is an acceptable option, provided the services of an experienced endoscopist are available.</li><li>➤ Biliary reconstruction in the presence of peritonitis, combined vascular and bile duct injuries and injury at or above the level of the biliary bifurcation are significant predictors of poor surgical outcome.</li><li>➤ Roux en Y hepaticojejunostomy</li><li>➤ Ref: Bailey 28 th Ed. Pg 1252-53</li><li>➤ Ref:</li><li>➤ Bailey 28 th Ed. Pg 1252-53</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Waxing and waning type of jaundice is seen in which associated etiology of obstructive jaundice?", "options": [{"label": "A", "text": "CBD stones", "correct": false}, {"label": "B", "text": "Bile duct stricture after cholecystectomy", "correct": false}, {"label": "C", "text": "Parasitic obstruction", "correct": false}, {"label": "D", "text": "Peri ampullary carcinoma", "correct": true}], "correct_answer": "D. Peri ampullary carcinoma", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Periampullary carcinoma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: CBD stones often cause intermittent obstructive jaundice , which may present with biliary colic but not typically described as waxing and waning.</li><li>• Option A:</li><li>• CBD stones</li><li>• intermittent obstructive jaundice</li><li>• Option B: Bile duct strictures after cholecystectomy can cause progressive jaundice if the stricture worsens , but do not usually present with a waxing and waning pattern of jaundice.</li><li>• Option B:</li><li>• Bile duct strictures</li><li>• cholecystectomy can cause progressive jaundice if the stricture worsens</li><li>• Option C: Parasitic obstruction , such as by liver flukes , can cause fluctuating jaundice due to intermittent bile duct obstruction , but it is not classically described as waxing and waning.</li><li>• Option C:</li><li>• Parasitic obstruction</li><li>• liver flukes</li><li>• fluctuating jaundice due to intermittent bile duct obstruction</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The waxing and waning type of jaundice is most characteristically associated with periampullary carcinoma due to intermittent obstruction of the bile duct . This pattern is caused by variable obstruction , which can be partial or complete at different times due to tumor dynamics . Recognizing this presentation is important for the timely diagnosis and management of this condition.</li><li>➤ waxing and waning type of jaundice</li><li>➤ associated with periampullary carcinoma</li><li>➤ intermittent obstruction of the bile duct</li><li>➤ pattern is caused by variable obstruction</li><li>➤ partial or complete at different times</li><li>➤ tumor dynamics</li><li>➤ Peri ampullary carcinoma includes:</li><li>➤ Peri ampullary carcinoma includes:</li><li>➤ Carcinoma of head of pancreas Distal CBD cancer Ampullary carcinoma Cancer in second part of duodenum</li><li>➤ Carcinoma of head of pancreas</li><li>➤ Distal CBD cancer</li><li>➤ Ampullary carcinoma</li><li>➤ Cancer in second part of duodenum</li><li>➤ Jaundice secondary to obstruction of the distal bile duct is the most common symptom that draws attention to ampullary and pancreatic head tumours.</li><li>➤ It is characteristically painless jaundice but may be associated with nausea and epigastric discomfort. These present with waxing and waning type of jaundice due to the fact that jaundice may intermittently wax and wane because of central necrosis and sloughing or pressure opening of a minimally obstructed duct.</li><li>➤ These present with waxing and waning type of jaundice due to the fact that jaundice may intermittently wax and wane because of central necrosis and sloughing or pressure opening of a minimally obstructed duct.</li><li>➤ OJ due to CBD stones is usually intermittent in nature with biliary colic.</li><li>➤ Pruritus, dark urine, and pale stools with steatorrhea are common accompaniments of jaundice.</li><li>➤ Ref: Bailey 28 th Ed. PG 1282</li><li>➤ Ref: Bailey 28 th Ed. PG 1282</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which is the most common location of cholangiocarcinomas?", "options": [{"label": "A", "text": "Distal bile duct", "correct": false}, {"label": "B", "text": "Hilum", "correct": true}, {"label": "C", "text": "Intra hepatic ducts", "correct": false}, {"label": "D", "text": "Junction of CHD and cystic duct", "correct": false}], "correct_answer": "B. Hilum", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B. Hilum</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Cholangiocarcinoma is an uncommon malignancy. The male-to-female ratio is approximately 1.5:1 . Anatomically, tumours involving the biliary confluence (hilar cholangiocarcinoma or Klatskin tumours) account for 60% of cases , with the remainder involving the distal bile duct (20–30%) or intrahepatic ducts (10–20%).</li><li>• Cholangiocarcinoma is an uncommon malignancy.</li><li>• Cholangiocarcinoma</li><li>• uncommon malignancy.</li><li>• The male-to-female ratio is approximately 1.5:1 .</li><li>• male-to-female ratio</li><li>• 1.5:1</li><li>• Anatomically, tumours involving the biliary confluence (hilar cholangiocarcinoma or Klatskin tumours) account for 60% of cases , with the remainder involving the distal bile duct (20–30%) or intrahepatic ducts (10–20%).</li><li>• biliary confluence</li><li>• account for 60% of cases</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Hilar cholangiocarcinoma is the most common type of cholangiocarcinoma , representing 60% of cases , with a male predominance . Understanding the anatomical distribution of cholangiocarcinomas is crucial for diagnosis and surgical planning.</li><li>➤ Hilar cholangiocarcinoma</li><li>➤ most common type of cholangiocarcinoma</li><li>➤ 60% of cases</li><li>➤ male predominance</li><li>➤ Ref : Bailey 28 th Ed. Pg 1256</li><li>➤ Ref : Bailey 28 th Ed. Pg 1256</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Choose the most common risk factor for cholangiocarcinoma in the western world:", "options": [{"label": "A", "text": "Hepatolithiasis", "correct": false}, {"label": "B", "text": "Choledochal cysts", "correct": false}, {"label": "C", "text": "Primary sclerosing cholangitis", "correct": true}, {"label": "D", "text": "Hepatitis C infection", "correct": false}], "correct_answer": "C. Primary sclerosing cholangitis", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/screenshot-2024-03-28-182308.jpg"], "explanation": "<p><strong>Ans. C. Primary sclerosing cholangitis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Hepatolithiasis refers to the presence of stones in the intrahepatic bile ducts and is a risk factor for cholangiocarcinoma , especially in Asian populations.</li><li>• Option A:</li><li>• Hepatolithiasis</li><li>• presence of stones in the intrahepatic bile ducts</li><li>• risk factor for cholangiocarcinoma</li><li>• Asian populations.</li><li>• Option B: Choledochal cysts are congenital malformations of the bile ducts and are associated with an increased risk of developing cholangiocarcinoma over a person's lifetime.</li><li>• Option B:</li><li>• Choledochal cysts</li><li>• congenital malformations</li><li>• bile ducts</li><li>• Option D: Hepatitis C infection can lead to chronic liver disease and cirrhosis , which are risk factors for liver cancer, including hepatocellular carcinoma and, to a lesser extent, cholangiocarcinoma.</li><li>• Option D:</li><li>• Hepatitis C infection</li><li>• chronic liver disease and cirrhosis</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The primary risk factor for cholangiocarcinoma in Western practice is primary sclerosing cholangitis , which significantly increases the risk of developing this cancer , particularly in patients with a concurrent inflammatory bowel disease.</li><li>➤ primary risk factor for cholangiocarcinoma</li><li>➤ Western practice</li><li>➤ primary sclerosing cholangitis</li><li>➤ increases the risk of developing this cancer</li><li>➤ concurrent inflammatory bowel disease.</li><li>➤ Minority of patients have a known risk factor; the major risk factor in western practice is PSC. It is estimated that a longstanding history of PSC increases the risk of developing biliary tract cancer 20-fold compared with the normal population; those with concomitant IBD are at significantly higher risk. Cholangiocarcinoma appears to occur at an earlier age in patients with PSC (30–50 years of age) than in the general population. Congenital cystic disease, hepatolithiasis, oriental cholangiohepatitis, hepatitis C virus infection and infestation with liver flukes have also been associated with an increased risk of cholangiocarcinoma.</li><li>➤ Minority of patients have a known risk factor; the major risk factor in western practice is PSC. It is estimated that a longstanding history of PSC increases the risk of developing biliary tract cancer 20-fold compared with the normal population; those with concomitant IBD are at significantly higher risk.</li><li>➤ Cholangiocarcinoma appears to occur at an earlier age in patients with PSC (30–50 years of age) than in the general population.</li><li>➤ Congenital cystic disease, hepatolithiasis, oriental cholangiohepatitis, hepatitis C virus infection and infestation with liver flukes have also been associated with an increased risk of cholangiocarcinoma.</li><li>➤ Ref : Bailey 28 th Ed. Pg 1256</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 1256</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient presented with recurrent attacks of acute pancreatitis since childhood. Pancreas divisum was suspected. What will be your investigation of choice in this scenario?", "options": [{"label": "A", "text": "MRCP", "correct": true}, {"label": "B", "text": "EUS", "correct": false}, {"label": "C", "text": "Serum lipase", "correct": false}, {"label": "D", "text": "USG abdomen", "correct": false}], "correct_answer": "A. MRCP", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture35.jpg"], "explanation": "<p><strong>Ans. A) MRCP</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: EUS (Endoscopic Ultrasound) can also be used to evaluate the pancreas and pancreatic duct , but MRCP is generally preferred for its non-invasive nature.</li><li>• Option B:</li><li>• EUS</li><li>• used to evaluate the pancreas and pancreatic duct</li><li>• Option C: Serum lipase is a blood test used to diagnose pancreatitis but is not the primary investigation for pancreas divisum.</li><li>• Option C:</li><li>• Serum lipase is a blood test used to diagnose pancreatitis</li><li>• Option D: Abdominal ultrasound (USG) is a useful imaging modality but may not provide the detailed visualization of the pancreatic ducts required for diagnosing pancreas divisum.</li><li>• Option D:</li><li>• Abdominal ultrasound</li><li>• useful imaging modality</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In cases of suspected pancreas divisum , MRCP is the investigation of choice due to its non-invasive nature and ability to provide detailed images of the pancreatic ducts , helping to confirm the diagnosis and guide further management.</li><li>➤ suspected pancreas divisum</li><li>➤ MRCP</li><li>➤ investigation of choice due to its non-invasive nature</li><li>➤ ability to provide detailed images of the pancreatic ducts</li><li>➤ Pancreas divisum occurs when the embryological ventral and dorsal parts of the pancreas fail to fuse. The dorsal pancreatic duct becomes the main pancreatic duct and drains most of the pancreas through the minor or accessory papilla. The minor papilla is substantially smaller than the major papilla, thus large volumes of secretions flowing through a narrow papilla leads to incomplete drainage, which may in turn cause obstructive pain or pancreatitis. It should be excluded in patients with idiopathic recurrent pancreatitis. The diagnosis can be arrived at by MRCP (IOC), EUS or ERCP, augmented by injection of secretin if necessary. There may be changes indicative of obstruction or chronic inflammation in the dorsal duct system. Endoscopic sphincterotomy and stenting of the minor papilla may relieve the symptoms. Surgical intervention can take the form of sphincteroplasty, pancreaticojejunostomy or even resection of the pancreatic head.</li><li>➤ Pancreas divisum occurs when the embryological ventral and dorsal parts of the pancreas fail to fuse. The dorsal pancreatic duct becomes the main pancreatic duct and drains most of the pancreas through the minor or accessory papilla.</li><li>➤ The minor papilla is substantially smaller than the major papilla, thus large volumes of secretions flowing through a narrow papilla leads to incomplete drainage, which may in turn cause obstructive pain or pancreatitis. It should be excluded in patients with idiopathic recurrent pancreatitis.</li><li>➤ The diagnosis can be arrived at by MRCP (IOC), EUS or ERCP, augmented by injection of secretin if necessary. There may be changes indicative of obstruction or chronic inflammation in the dorsal duct system.</li><li>➤ Endoscopic sphincterotomy and stenting of the minor papilla may relieve the symptoms. Surgical intervention can take the form of sphincteroplasty, pancreaticojejunostomy or even resection of the pancreatic head.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1267</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1267</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is a pre sinusoidal cause of portal HTN?", "options": [{"label": "A", "text": "Cirrhosis", "correct": false}, {"label": "B", "text": "Budd Chiari syndrome", "correct": false}, {"label": "C", "text": "Congestive cardiac failure", "correct": false}, {"label": "D", "text": "Congenital hyper-coagulable states", "correct": true}], "correct_answer": "D. Congenital hyper-coagulable states", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D. Congenital hyper- coagulable states</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Causes of portal hypertension</li><li>• 1. Pre-sinusoidal</li><li>• Pre-sinusoidal</li><li>• Extrahepatic : portal vein thrombosis, splenic vein thrombosis (pancreatitis, pancreatic tumour), myelofibrosis, tropical splenomegaly</li><li>• Extrahepatic</li><li>• Intrahepatic : schistosomiasis, congenital hepatic fibrosis and portal infltration (sarcoidosis), drugs and toxins, veno-occlusive disease</li><li>• Intrahepatic</li><li>• 2. Sinusoidal</li><li>• Sinusoidal</li><li>• Cirrhosis</li><li>• Cirrhosis</li><li>• 3. Post-sinusoidal</li><li>• Post-sinusoidal</li><li>• Hepatic vein occlusion (Budd–Chiari syndrome), veno- occlusive disease, congestive cardiac failure.</li><li>• Ref : Bailey: 28 th Ed. Pg 1203</li><li>• Ref : Bailey: 28 th Ed. Pg 1203</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Following an alcohol binge, a patient presented with features of acute abdominal pain radiating to the back and relieved on sitting bending forwards, since 24 hours. USG abdomen was normal. What is your next step?", "options": [{"label": "A", "text": "Immediate CT scan abdomen", "correct": false}, {"label": "B", "text": "Liver function tests", "correct": false}, {"label": "C", "text": "Serum lipase", "correct": true}, {"label": "D", "text": "Blood culture", "correct": false}], "correct_answer": "C. Serum lipase", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Serum Lipase</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Immediate CT scan abdomen may provide detailed information about the pancreas and surrounding structures, but it is not the initial step in the evaluation of acute pancreatitis. Serum lipase or amylase levels are typically checked first.</li><li>• Option A:</li><li>• Immediate CT scan abdomen</li><li>• information about the pancreas and surrounding structures,</li><li>• not the initial step</li><li>• Option B: Liver function tests are not the first-line investigation for suspected acute pancreatitis. Lipase or amylase levels are more relevant in this context.</li><li>• Option B:</li><li>• Liver function tests</li><li>• not the first-line investigation</li><li>• Option D: Blood culture is not the primary investigation for diagnosing acute pancreatitis. It is used in cases of suspected infection but is not the initial step in the evaluation of pancreatitis.</li><li>• Option D:</li><li>• Blood culture</li><li>• not the primary investigation for diagnosing acute pancreatitis.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In a patient with suspected acute pancreatitis following alcohol binge and characteristic symptoms , the next step is to check serum lipase levels. Elevated lipase levels are a reliable indicator of acute pancreatitis , and this test is more specific and sensitive than serum amylase.</li><li>➤ acute pancreatitis</li><li>➤ alcohol binge and characteristic symptoms</li><li>➤ serum lipase</li><li>➤ Elevated lipase levels</li><li>➤ acute pancreatitis</li><li>➤ Diagnosis in acute pancreatitis is usually made based on clinical presentation and elevated amylase / lipase levels. A serum amylase level 3 times above normal is indicative of the disease. However, a normal amylase level does not exclude acute pancreatitis, particularly if there is a delay in presentation. The serum lipase level provides a more sensitive and specific test than amylase. CECT is the best test, but usually not required for diagnosis.</li><li>➤ Diagnosis in acute pancreatitis is usually made based on clinical presentation and elevated amylase / lipase levels.</li><li>➤ A serum amylase level 3 times above normal is indicative of the disease.</li><li>➤ However, a normal amylase level does not exclude acute pancreatitis, particularly if there is a delay in presentation.</li><li>➤ The serum lipase level provides a more sensitive and specific test than amylase.</li><li>➤ The serum lipase level provides a more sensitive and specific test than amylase.</li><li>➤ CECT is the best test, but usually not required for diagnosis.</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1271</li><li>➤ Ref:</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 1271</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In a case of severe acute pancreatitis, to differentiate interstitial from necrotizing pancreatitis, when is the ideal time to get a CECT done?", "options": [{"label": "A", "text": "Within first 24 hours of symptoms", "correct": false}, {"label": "B", "text": "Immediately on arrival", "correct": false}, {"label": "C", "text": "After 48 hours of admission", "correct": false}, {"label": "D", "text": "After 72 hours of symptoms", "correct": true}], "correct_answer": "D. After 72 hours of symptoms", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture38.jpg"], "explanation": "<p><strong>Ans. D) After 72hours of symptoms</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• In the first 72 hours , CT may underestimate the extent of necrosis . Thus, the ideal time to perform a CECT would be after 72 hours of symptoms .</li><li>• first 72 hours</li><li>• CT may underestimate the extent of necrosis</li><li>• ideal time to perform a CECT would be after 72 hours of symptoms</li><li>• .</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In cases of severe acute pancreatitis , the ideal time to perform a contrast-enhanced CT (CECT) to differentiate interstitial from necrotizing pancreatitis is after 72 hours of symptoms . CT performed earlier, within the first 72 hours, may underestimate the extent of necrosis.</li><li>➤ severe acute pancreatitis</li><li>➤ ideal time to perform a contrast-enhanced CT</li><li>➤ after 72 hours of symptoms</li><li>➤ A contrast-enhanced CT is indicated in the following situations:</li><li>➤ A contrast-enhanced CT is indicated in the following situations:</li><li>➤ If there is diagnostic uncertainty. In patients with severe acute pancreatitis to distinguish interstitial from necrotizing pancreatitis. In the first 72 hours, CT may underestimate the extent of necrosis. The severity of pancreatitis detected on CT maybe staged according to the Balthazar criteria. In patients with organ failure, signs of sepsis or progressive clinical deterioration. When a localized complication is suspected, such as fluid collection, pseudocyst or a pseudo aneurysm.</li><li>➤ If there is diagnostic uncertainty.</li><li>➤ In patients with severe acute pancreatitis to distinguish interstitial from necrotizing pancreatitis. In the first 72 hours, CT may underestimate the extent of necrosis. The severity of pancreatitis detected on CT maybe staged according to the Balthazar criteria.</li><li>➤ In patients with organ failure, signs of sepsis or progressive clinical deterioration.</li><li>➤ When a localized complication is suspected, such as fluid collection, pseudocyst or a pseudo aneurysm.</li><li>➤ Other imaging in acute pancreatitis-</li><li>➤ Other imaging in acute pancreatitis-</li><li>➤ X-ray- Plain erect chest and abdominal radiographs are not diagnostic of acute pancreatitis but are useful in the differential diagnosis. Non-specific findings in pancreatitis include a generalised or local ileus (sentinel loop), a colon cut-off sign (image), gasless abdomen and a renal halo sign.</li><li>➤ USG - does not establish a diagnosis of acute pancreatitis. The swollen pancreas may be seen, but ultrasonography should be performed within 24 hours in all patients to detect gallstones as a potential cause, rule out acute cholecystitis as a differential diagnosis and determine whether the common bile duct is dilated. MRI can yield similar information to that obtained by CT. EUS and MRCP can help in detecting stones in the common bile duct and directly assessing the pancreatic parenchyma. ERCP allows the identification and removal of stones in the common bile duct in gallstone pancreatitis. In patients with severe acute gallstone pancreatitis and signs of ongoing biliary obstruction and cholangitis, an urgent ERCP should be sought.</li><li>➤ USG - does not establish a diagnosis of acute pancreatitis. The swollen pancreas may be seen, but ultrasonography should be performed within 24 hours in all patients to detect gallstones as a potential cause, rule out acute cholecystitis as a differential diagnosis and determine whether the common bile duct is dilated.</li><li>➤ USG</li><li>➤ MRI can yield similar information to that obtained by CT. EUS and MRCP can help in detecting stones in the common bile duct and directly assessing the pancreatic parenchyma.</li><li>➤ MRI</li><li>➤ ERCP allows the identification and removal of stones in the common bile duct in gallstone pancreatitis. In patients with severe acute gallstone pancreatitis and signs of ongoing biliary obstruction and cholangitis, an urgent ERCP should be sought.</li><li>➤ ERCP</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1272</li><li>➤ Ref:</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 1272</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All the following are a part of the BISAP score except?", "options": [{"label": "A", "text": "BUN", "correct": false}, {"label": "B", "text": "SIRS", "correct": false}, {"label": "C", "text": "Impaired mental status", "correct": false}, {"label": "D", "text": "PT (prothrombin time) increase", "correct": true}], "correct_answer": "D. PT (prothrombin time) increase", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) PT (Prothrombin time) increase</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation :</li><li>• Abnormal PT is not a component of BISAP.</li><li>• Abnormal PT</li><li>• not a component of BISAP.</li><li>• BISAP stands for Bedside Index for Severity in Acute Pancreatitis. It allows for early identification of patients at increased risk for in-hospital mortality.</li><li>• BISAP stands</li><li>• Bedside Index for Severity in Acute Pancreatitis.</li><li>• early identification of patients</li><li>• increased risk for in-hospital mortality.</li><li>• It includes 5 parameters-</li><li>• It includes 5 parameters-</li><li>• Blood urea nitrogen (BUN) &gt;25 mg/dl Impaired mental status Systemic inflammatory response syndrome (SIRS) Age &gt;60 years Presence of a pleural effusion.</li><li>• Blood urea nitrogen (BUN) &gt;25 mg/dl</li><li>• Impaired mental status</li><li>• Systemic inflammatory response syndrome (SIRS)</li><li>• Age &gt;60 years</li><li>• Presence of a pleural effusion.</li><li>• 1 point each Score up to 2- low risk of mortality &gt; 3 - high risk of mortality</li><li>• 1 point each</li><li>• Score up to 2- low risk of mortality</li><li>• &gt; 3 - high risk of mortality</li><li>• Severity stratification assessments should be performed in patients at 24 hours, 48 hours and 7 days after admission .</li><li>• Severity stratification assessments should be performed in patients at 24 hours, 48 hours and 7 days after admission</li><li>• The Ranson and Glasgow scoring systems are specific for acute pancreatitis, and a score of 3 or more at 48 hours indicates a severe attack. Several other systems that are used in intensive care units can also be applied. These include the APACHE, SAPS, SOFA, MODS and modified Marshall scoring systems (the latter has the advantage of simplicity). Regardless of the system used, persisting organ failure indicates a severe attack. A serum C-reactive protein level &gt;150 mg/L at 48 hours after the onset of symptoms is also an indicator of severity. Patients with a body mass index over 30 are at higher risk of developing complications</li><li>• The Ranson and Glasgow scoring systems are specific for acute pancreatitis, and a score of 3 or more at 48 hours indicates a severe attack.</li><li>• The Ranson and Glasgow</li><li>• Several other systems that are used in intensive care units can also be applied. These include the APACHE, SAPS, SOFA, MODS and modified Marshall scoring systems (the latter has the advantage of simplicity). Regardless of the system used, persisting organ failure indicates a severe attack.</li><li>• APACHE, SAPS, SOFA, MODS</li><li>• A serum C-reactive protein level &gt;150 mg/L at 48 hours after the onset of symptoms is also an indicator of severity.</li><li>• C-reactive protein level &gt;150 mg/L at 48 hours</li><li>• Patients with a body mass index over 30 are at higher risk of developing complications</li><li>• body mass index over 30</li><li>• Ref: Bailey 28 th Ed. Pg 1271</li><li>• Ref:</li><li>• Bailey 28 th Ed. Pg 1271</li><li>• Online: https://www.mdapp.co/bisap-pancreatitis-score-calculator</li><li>• Online: https://www.mdapp.co/bisap-pancreatitis-score-calculator</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of these are components of treatment protocol mild acute pancreatitis except?", "options": [{"label": "A", "text": "Antibiotics", "correct": true}, {"label": "B", "text": "Analgesics", "correct": false}, {"label": "C", "text": "Antiemetic", "correct": false}, {"label": "D", "text": "IV fluids", "correct": false}], "correct_answer": "A. Antibiotics", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Antibiotics</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Analgesics. Since pain is a common and significant symptom, pain management is an important component of the treatment protocol.</li><li>• Option B: Analgesics.</li><li>• pain management</li><li>• component of the treatment protocol.</li><li>• Option C: Antiemetic. Antiemetics may be used to manage nausea and vomiting , which are common symptoms associated with acute pancreatitis.</li><li>• Option C: Antiemetic.</li><li>• used to manage nausea and vomiting</li><li>• Option D: IV fluids. Intravenous fluids are crucial in the management of mild acute pancreatitis to ensure adequate hydration , as patients may not be able to take adequate fluids orally due to nausea or vomiting.</li><li>• Option D: IV fluids.</li><li>• management of mild acute pancreatitis</li><li>• ensure adequate hydration</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In the management of mild acute pancreatitis, analgesics and antiemetics are commonly used to control symptoms , IV fluids are essential to maintain hydration , but antibiotics are not indicated unless there is a specific complication like infected necrosis.</li><li>➤ mild acute pancreatitis, analgesics and antiemetics</li><li>➤ control symptoms</li><li>➤ IV fluids are essential to maintain hydration</li><li>➤ antibiotics are not indicated</li><li>➤ In a mild attack of pancreatitis, a conservative approach is indicated with intravenous fluid administration and frequent, but non-invasive, observation. A brief period of fasting may be sensible in a patient who is nauseated and in pain, but there is little physiological justification for keeping patients on a prolonged ‘nil by mouth’ regimen. Antibiotics are not indicated. Apart from analgesics and anti-emetics, no drugs or interventions are warranted. CT scanning is unnecessary unless there is evidence of deterioration.</li><li>➤ In a mild attack of pancreatitis, a conservative approach is indicated with intravenous fluid administration and frequent, but non-invasive, observation. A brief period of fasting may be sensible in a patient who is nauseated and in pain, but there is little physiological justification for keeping patients on a prolonged ‘nil by mouth’ regimen.</li><li>➤ there is little physiological justification for keeping patients on a prolonged ‘nil by mouth’ regimen.</li><li>➤ Antibiotics are not indicated.</li><li>➤ Antibiotics are not indicated.</li><li>➤ Apart from analgesics and anti-emetics, no drugs or interventions are warranted.</li><li>➤ CT scanning is unnecessary unless there is evidence of deterioration.</li><li>➤ CT scanning is unnecessary unless there is evidence of deterioration.</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1273</li><li>➤ Ref:</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 1273</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these cannot be used as an indicator of severity in acute pancreatitis?", "options": [{"label": "A", "text": "CRP", "correct": false}, {"label": "B", "text": "SOFA score", "correct": false}, {"label": "C", "text": "Serum lipase levels", "correct": true}, {"label": "D", "text": "CT scan", "correct": false}], "correct_answer": "C. Serum lipase levels", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/screenshot-2024-03-28-182552.jpg"], "explanation": "<p><strong>Ans. C) Serum Lipase levels</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: CRP (C-Reactive Protein) . CRP is an acute-phase reactant that can be used as an indicator of severity in acute pancreatitis . A CRP level greater than 150 mg/L at 48 hours after the onset of symptoms is considered predictive of severe pancreatitis.</li><li>• Option A:</li><li>• CRP (C-Reactive Protein)</li><li>• acute-phase reactant</li><li>• used as an indicator of severity in acute pancreatitis</li><li>• Option B: SOFA Score (Sequential Organ Failure Assessment) . The SOFA score is used in critical care to assess and track the extent of a patient's organ function or rate of failure . In the context of acute pancreatitis, an increasing SOFA score can indicate persistent and severe organ failure, which correlates with the severity of the disease.</li><li>• Option B:</li><li>• SOFA Score (Sequential Organ Failure Assessment)</li><li>• SOFA score</li><li>• critical care to assess and track the extent of a patient's organ function</li><li>• rate of failure</li><li>• Option D: CT scan . A CT scan can be used to assess the severity of acute pancreatitis , especially in distinguishing between interstitial and necrotizing forms of the disease . The severity on a CT scan can be staged according to the Balthazar criteria.</li><li>• Option D:</li><li>• CT scan</li><li>• used to assess the severity of acute pancreatitis</li><li>• distinguishing between interstitial and necrotizing forms of the disease</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ While serum lipase levels are used for the diagnosis of acute pancreatitis , they are not indicators of disease severity . Instead, CRP levels , various scoring systems like SOFA , and CT scans are used to assess the severity and potential complications of acute pancreatitis.</li><li>➤ serum lipase levels</li><li>➤ used for the diagnosis of acute pancreatitis</li><li>➤ not indicators of disease severity</li><li>➤ CRP levels</li><li>➤ various scoring systems like SOFA</li><li>➤ CT scans are used to assess the severity</li><li>➤ A severe attack may be heralded by an initial clinical impression of a very ill patient and a worsening physiological state at 24–48 hours. Various prognostic scoring systems have been used, all aimed at predicting persistent organ failure, particularly respiratory, cardiac and renal. The Ranson and Glasgow scoring systems are specific for acute pancreatitis , and a score of 3 or more at 48 hours indicates a severe attack . Several other systems that are used in intensive care units can also be applied. These include the APACHE, SAPS, SOFA, MODS and modified Marshall scoring systems. Regardless of the system used, persisting organ failure indicates a severe attack. A serum C-reactive protein level &gt;150 mg/L at 48 hours after the onset of symptoms is also an indicator of severity. Patients with a body mass index over 30 are at higher risk of developing complications. In patients with severe acute pancreatitis to distinguish interstitial from necrotising pancreatitis. In the first 72 hours, CT may underestimate the extent of necrosis. The severity of pancreatitis detected on CT may be staged according to the Balthazar criteria.</li><li>➤ A severe attack may be heralded by an initial clinical impression of a very ill patient and a worsening physiological state at 24–48 hours.</li><li>➤ Various prognostic scoring systems have been used, all aimed at predicting persistent organ failure, particularly respiratory, cardiac and renal.</li><li>➤ The Ranson and Glasgow scoring systems are specific for acute pancreatitis , and a score of 3 or more at 48 hours indicates a severe attack .</li><li>➤ Ranson and Glasgow scoring systems</li><li>➤ acute pancreatitis</li><li>➤ score of 3 or more at 48 hours indicates a severe attack</li><li>➤ Several other systems that are used in intensive care units can also be applied.</li><li>➤ These include the APACHE, SAPS, SOFA, MODS and modified Marshall scoring systems.</li><li>➤ Regardless of the system used, persisting organ failure indicates a severe attack.</li><li>➤ A serum C-reactive protein level &gt;150 mg/L at 48 hours after the onset of symptoms is also an indicator of severity.</li><li>➤ Patients with a body mass index over 30 are at higher risk of developing complications.</li><li>➤ In patients with severe acute pancreatitis to distinguish interstitial from necrotising pancreatitis. In the first 72 hours, CT may underestimate the extent of necrosis. The severity of pancreatitis detected on CT may be staged according to the Balthazar criteria.</li><li>➤ Ranson score:</li><li>➤ Ranson score:</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1271-72</li><li>➤ Ref:</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 1271-72</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is an incorrect statement about pancreatic pseudocyst?", "options": [{"label": "A", "text": "Develops after 4 weeks of acute attack of pancreatitis.", "correct": false}, {"label": "B", "text": "Amylase levels are high, but CEA levels are low in cyst fluid.", "correct": false}, {"label": "C", "text": "More than half of pancreatic pseudocysts have communication with the main pancreatic duct.", "correct": false}, {"label": "D", "text": "Percutaneous drainage to the exterior is the treatment of choice.", "correct": true}], "correct_answer": "D. Percutaneous drainage to the exterior is the treatment of choice.", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Percutaneous drainage to the exterior is the treatment of choice.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Develops after 4 weeks of acute attack of pancreatitis. This statement is correct . A pseudocyst is a collection of pancreatic secretions enclosed by a nonepithelialized wall of fibrous or granulation tissue that typically forms at least 4 weeks following an episode of acute pancreatitis.</li><li>• Option A:</li><li>• Develops after 4 weeks of acute attack of pancreatitis.</li><li>• correct</li><li>• Option B: Amylase levels are high but CEA levels are low in cyst fluid. This statement is correct . The fluid within a pancreatic pseudocyst typically has high amylase levels due to its pancreatic origin, and low CEA levels; elevated CEA levels may indicate a mucinous neoplasm rather than a pseudocyst.</li><li>• Option B:</li><li>• Amylase levels are high but CEA levels are low in cyst fluid.</li><li>• correct</li><li>• Option C: More than half of pancreatic pseudocysts have communication with the main pancreatic duct . This statement is correct . Many pseudocysts communicate with the pancreatic ductal system, which can have implications for treatment, particularly if drainage is being considered.</li><li>• Option C:</li><li>• More than half of pancreatic pseudocysts have communication with the main pancreatic duct</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Pancreatic pseudocysts form after an episode of acute pancreatitis and contain high amylase and low CEA levels . Percutaneous drainage to the exterior is not the treatment of choice due to high recurrence risk , and alternative drainage methods should be considered if intervention is required.</li><li>➤ Pancreatic pseudocysts</li><li>➤ episode of acute pancreatitis</li><li>➤ contain high amylase and low CEA levels</li><li>➤ Percutaneous drainage</li><li>➤ exterior is not the treatment of choice</li><li>➤ high recurrence risk</li><li>➤ A pseudocyst is a collection of amylase-rich fluid enclosed in a well-defined wall of fibrous or granulation tissue. Pseudocysts typically arise following an attack of acute pancreatitis. Formation of a pseudocyst requires 4 weeks or more from the onset of acute pancreatitis. More than half have communication with the main pancreatic duct. Fluid from a pseudocyst typically has a low CEA level, and levels above 400 ng/ml are suggestive of a mucinous neoplasm. Pseudocyst fluid usually has a high amylase level. Pseudocysts usually resolve spontaneously, but complications can develop. Pseudocysts that are thick walled or large (&gt;6 cm in diameter), have lasted for a long time (over 12 weeks) or have arisen in the context of chronic pancreatitis are less likely to resolve spontaneously. Therapeutic intervention is advised only if the pseudocyst causes symptoms, complications develop, or distinction has to be made between a pseudocyst and a tumor. There are three possible approaches to draining a pseudocyst: percutaneous, endoscopic and surgical. Percutaneous drainage to the exterior under radiological guidance should be avoided. It carries a very high likelihood of recurrence. Moreover, it is not advisable unless one is certain that the cyst is not neoplastic and that it has no communication with the pancreatic duct (or else a pancreatico-cutaneous fistula will develop). A percutaneous transgastric cyst o gastrostomy can be performed under imaging guidance, and a double-pigtail drain placed with one end in the cyst cavity and the other end in the gastric lumen. Endoscopic drainage usually involves puncture of the cyst through the stomach or duodenal wall under endoscopic ultrasound guidance, and placement of a tube drain with one end in the cyst cavity and the other end in the gastric lumen. Occasionally, ERCP and placement of a pancreatic stent across the ampulla may help to drain a pseudocyst that is in communication with the duct. Surgical drainage involves internally draining the cyst into the gastric or jejunal lumen. The approach is conventionally through an open incision, but laparoscopic cysto-gastrostomy is also feasible. Pseudocysts that have developed complications are best managed surgically.</li><li>➤ A pseudocyst is a collection of amylase-rich fluid enclosed in a well-defined wall of fibrous or granulation tissue. Pseudocysts typically arise following an attack of acute pancreatitis. Formation of a pseudocyst requires 4 weeks or more from the onset of acute pancreatitis.</li><li>➤ More than half have communication with the main pancreatic duct.</li><li>➤ Fluid from a pseudocyst typically has a low CEA level, and levels above 400 ng/ml are suggestive of a mucinous neoplasm. Pseudocyst fluid usually has a high amylase level.</li><li>➤ Pseudocysts usually resolve spontaneously, but complications can develop.</li><li>➤ Pseudocysts that are thick walled or large (&gt;6 cm in diameter), have lasted for a long time (over 12 weeks) or have arisen in the context of chronic pancreatitis are less likely to resolve spontaneously.</li><li>➤ Therapeutic intervention is advised only if the pseudocyst causes symptoms, complications develop, or distinction has to be made between a pseudocyst and a tumor.</li><li>➤ There are three possible approaches to draining a pseudocyst: percutaneous, endoscopic and surgical. Percutaneous drainage to the exterior under radiological guidance should be avoided. It carries a very high likelihood of recurrence. Moreover, it is not advisable unless one is certain that the cyst is not neoplastic and that it has no communication with the pancreatic duct (or else a pancreatico-cutaneous fistula will develop).</li><li>➤ percutaneous, endoscopic and surgical. Percutaneous drainage to the exterior under radiological guidance should be avoided. It carries a very high likelihood of recurrence.</li><li>➤ A percutaneous transgastric cyst o gastrostomy can be performed under imaging guidance, and a double-pigtail drain placed with one end in the cyst cavity and the other end in the gastric lumen.</li><li>➤ Endoscopic drainage usually involves puncture of the cyst through the stomach or duodenal wall under endoscopic ultrasound guidance, and placement of a tube drain with one end in the cyst cavity and the other end in the gastric lumen.</li><li>➤ Occasionally, ERCP and placement of a pancreatic stent across the ampulla may help to drain a pseudocyst that is in communication with the duct.</li><li>➤ Surgical drainage involves internally draining the cyst into the gastric or jejunal lumen. The approach is conventionally through an open incision, but laparoscopic cysto-gastrostomy is also feasible. Pseudocysts that have developed complications are best managed surgically.</li><li>➤ Pseudocysts that have developed complications are best managed surgically.</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1277</li><li>➤ Ref:</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 1277</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is not complication of a pancreatic pseudocyst?", "options": [{"label": "A", "text": "Peritonitis", "correct": false}, {"label": "B", "text": "Obstructive jaundice", "correct": false}, {"label": "C", "text": "GI Bleed", "correct": false}, {"label": "D", "text": "Paraplegia", "correct": true}], "correct_answer": "D. Paraplegia", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/screenshot-2024-03-28-182648.jpg"], "explanation": "<p><strong>Ans. D) Paraplegia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Possible complications of pancreatic pseudocyst:</li><li>• Possible complications of pancreatic pseudocyst:</li><li>• Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1277</li><li>• Ref:</li><li>• Bailey and Love’s Short Practice of Surgery 28th Edition Page 1277</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient was diagnosed with chronic pancreatitis. What is the most common cause of this condition?", "options": [{"label": "A", "text": "Gallstones", "correct": false}, {"label": "B", "text": "Alcohol", "correct": true}, {"label": "C", "text": "Tropical pancreatitis", "correct": false}, {"label": "D", "text": "Hereditary pancreatitis", "correct": false}], "correct_answer": "B. Alcohol", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Alcohol</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Gallstones . Gallstones are a common cause of acute pancreatitis but are not the most common cause of chronic pancreatitis . They can lead to chronic pancreatitis if recurrent episodes of acute pancreatitis occur due to gallstone obstruction.</li><li>• Option A:</li><li>• Gallstones</li><li>• common cause of acute pancreatitis</li><li>• not the most common cause of chronic pancreatitis</li><li>• Option C: Tropical pancreatitis . Tropical pancreatitis is a type of chronic pancreatitis that is observed in tropical regions , often associated with dietary factors such as cassava consumption and exposure to certain toxins, but it is not the most common cause globally.</li><li>• Option C:</li><li>• Tropical pancreatitis</li><li>• chronic pancreatitis that is observed in tropical regions</li><li>• Option D: Hereditary pancreatitis . Hereditary pancreatitis is a genetic condition caused by mutations, such as in the PRSS1 gene . It is an autosomal dominant disorder but is less common compared to alcohol-induced pancreatitis.</li><li>• Option D:</li><li>• Hereditary pancreatitis</li><li>• genetic condition caused by mutations, such as in the PRSS1 gene</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Alcohol consumption is the most common cause of chronic pancreatitis , especially in developed countries , due to its repeated damaging effects on the pancreatic tissue over time .</li><li>➤ Alcohol consumption</li><li>➤ most common cause of chronic pancreatitis</li><li>➤ developed countries</li><li>➤ repeated damaging effects on the pancreatic tissue over time</li><li>➤ Other causes of chronic pancreatitis-</li><li>➤ Other causes of chronic pancreatitis-</li><li>➤ Pancreatic duct obstruction due to stricture formation after trauma / acute pancreatitis / pancreatic cancer Congenital anomalies- pancreas divisum Hereditary pancreatitis- Autosomal Dominant disorder with gain of function mutation of PRSS 1 on chromosome 7 Idiopathic chronic pancreatitis due to loss of function mutation of SPINK 1 gene Cystic fibrosis Hyperlipidemia Hypercalcemia Tropical pancreatitis- risk factors include cassava, exposure to hydrocarbons. Autoimmune pancreatitis - IgG4 elevated.</li><li>➤ Pancreatic duct obstruction due to stricture formation after trauma / acute pancreatitis / pancreatic cancer</li><li>➤ Congenital anomalies- pancreas divisum</li><li>➤ Hereditary pancreatitis- Autosomal Dominant disorder with gain of function mutation of PRSS 1 on chromosome 7</li><li>➤ Idiopathic chronic pancreatitis due to loss of function mutation of SPINK 1 gene</li><li>➤ Cystic fibrosis</li><li>➤ Hyperlipidemia</li><li>➤ Hypercalcemia</li><li>➤ Tropical pancreatitis- risk factors include cassava, exposure to hydrocarbons.</li><li>➤ Autoimmune pancreatitis - IgG4 elevated.</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1278</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1278</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient presented with features of painless obstructive jaundice and deranged liver function tests. His gall bladder was distended. USG showed dilated common bile duct. What is the investigation of choice in this condition?", "options": [{"label": "A", "text": "ERCP", "correct": false}, {"label": "B", "text": "CECT abdomen", "correct": true}, {"label": "C", "text": "HIDA scan", "correct": false}, {"label": "D", "text": "PTC", "correct": false}], "correct_answer": "B. CECT abdomen", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) CECT Abdomen</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: ERCP (Endoscopic Retrograde Cholangiopancreatography). ERCP is an invasive procedure that combines endoscopy and fluoroscopy to diagnose and treat conditions associated with the biliary or pancreatic ductal systems . It is used to identify and treat obstructions but is not typically the first diagnostic test due to its invasiveness.</li><li>• Option A:</li><li>• ERCP (Endoscopic Retrograde Cholangiopancreatography).</li><li>• invasive procedure that combines endoscopy and fluoroscopy</li><li>• diagnose and treat conditions associated with the biliary or pancreatic ductal systems</li><li>• Option C: HIDA scan (Hepatobiliary Iminodiacetic Acid scan). A HIDA scan is a nuclear imaging procedure used to evaluate the health and function of the gallbladder and the flow of bile from the liver to the small intestine . It is not the primary investigation for detecting pancreatic or periampullary tumors.</li><li>• Option C:</li><li>• HIDA scan (Hepatobiliary Iminodiacetic Acid scan).</li><li>• nuclear imaging procedure used to evaluate the health and function of the gallbladder</li><li>• flow of bile</li><li>• liver to the small intestine</li><li>• Option D: PTC (Percutaneous Transhepatic Cholangiography). PTC is an imaging test that involves the injection of a contrast dye directly into the liver to visualize the bile ducts . It is used when there is suspicion of bile duct obstruction, but it is not the first line of investigation for periampullary tumors.</li><li>• Option D:</li><li>• PTC (Percutaneous Transhepatic Cholangiography).</li><li>• imaging test that involves the injection of a contrast dye directly into the liver</li><li>• visualize the bile ducts</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The investigation of choice for suspected periampullary cancer in a patient with painless obstructive jaundice is a contrast-enhanced CT scan of the abdomen , as it provides comprehensive imaging for diagnosis and surgical planning.</li><li>➤ investigation of choice for suspected periampullary cancer</li><li>➤ painless obstructive jaundice is a contrast-enhanced CT scan of the abdomen</li><li>➤ According to Courvoisier’s law, a palpable, non-tender gallbladder in the presence of jaundice is unlikely to be due to gallstones and usually results from a distal common duct obstruction secondary to periampullary malignancy. Investigation of choice for carcinoma of pancreatic head is contrast enhanced CT scan abdomen.</li><li>➤ According to Courvoisier’s law, a palpable, non-tender gallbladder in the presence of jaundice is unlikely to be due to gallstones and usually results from a distal common duct obstruction secondary to periampullary malignancy.</li><li>➤ Courvoisier’s law, a palpable, non-tender gallbladder in the presence of jaundice</li><li>➤ Investigation of choice for carcinoma of pancreatic head is contrast enhanced CT scan abdomen.</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1283</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1283</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient with carcinoma of the pancreatic head underwent surgery. All the following are done in the procedure shown below except.", "options": [{"label": "A", "text": "Hepaticojejunostomy", "correct": false}, {"label": "B", "text": "Resection of proximal jejunum", "correct": false}, {"label": "C", "text": "Caudate lobectomy", "correct": true}, {"label": "D", "text": "Cholecystectomy", "correct": false}], "correct_answer": "C. Caudate lobectomy", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/picture41.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Caudate lobectomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• The procedure shown is Whipple’s procedure.</li><li>• Whipple’s procedure.</li><li>• The operation has three distinct phases:</li><li>• The operation has three distinct phases:</li><li>• Exploration and assessment. Resection; Reconstruction.</li><li>• Exploration and assessment.</li><li>• Exploration and assessment.</li><li>• Resection;</li><li>• Resection;</li><li>• Reconstruction.</li><li>• Reconstruction.</li><li>• Structures removed:</li><li>• Structures removed:</li><li>• Head of pancreas Duodenum, proximal jejunum Common bile duct Gallbladder Distal stomach (removed in original Whipple’s but can be preserved in surgeries done these days) Lymph nodes</li><li>• Head of pancreas</li><li>• Head of pancreas</li><li>• Duodenum, proximal jejunum</li><li>• Duodenum, proximal jejunum</li><li>• Common bile duct</li><li>• Common bile duct</li><li>• Gallbladder</li><li>• Gallbladder</li><li>• Distal stomach (removed in original Whipple’s but can be preserved in surgeries done these days)</li><li>• Distal stomach (removed in original Whipple’s but can be preserved in surgeries done these days)</li><li>• Lymph nodes</li><li>• Lymph nodes</li><li>• Reconstruction- in this order-</li><li>• Reconstruction- in this order-</li><li>• Pancreaticojejunostomy Hepaticojejunostomy Duodenojejunostomy / Gastrojejunostomy</li><li>• Pancreaticojejunostomy</li><li>• Pancreaticojejunostomy</li><li>• Hepaticojejunostomy</li><li>• Hepaticojejunostomy</li><li>• Duodenojejunostomy / Gastrojejunostomy</li><li>• Duodenojejunostomy / Gastrojejunostomy</li><li>• Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1284-85</li><li>• Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1284-85</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Overwhelming post-splenectomy infection (OPSI) risk remains high till what duration after splenectomy?", "options": [{"label": "A", "text": "1 to 2 weeks", "correct": false}, {"label": "B", "text": "1 to 2 months", "correct": false}, {"label": "C", "text": "1 to 2 years", "correct": true}, {"label": "D", "text": "Life-long", "correct": false}], "correct_answer": "C. 1 to 2 years", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C. 1 to 2 years</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• OPSI is the most fatal complication whereas left lower lobe atelectasis is the most common complication of splenectomy. Post-splenectomy septicaemia may result from S. pneumoniae, Neisseria meningitides, Haemophilus influenzae or Escherichia coli . However, the risk is greater in the young patient, in splenectomised patients treated with chemoradiotherapy and in patients who have undergone splenectomy for thalassaemia, sickle cell disease and autoimmune anaemia or thrombocytopenia. Opportunist/overwhelming post splenectomy infection (OPSI) is a major concern. Most infections after splenectomy could be avoided through measures that include offering the patients appropriate and timely immunization, antibiotic prophylaxis, education and prompt treatment of infection. The benefit of prophylactic antibiotics in this setting remains controversial. It is thought that children who have undergone splenectomy before the age of 5 years should be treated with a daily dose of penicillin until the age of 10 years. Prophylaxis in older children should be continued at least until the age of 16 years , but its use is less well defined in adults. Furthermore, compliance is problematic in the long term but, as the risk of overwhelming sepsis is greatest within the first 2–3 years after splenectomy, it seems reasonable to give prophylaxis during this time .</li><li>• OPSI is the most fatal complication whereas left lower lobe atelectasis is the most common complication of splenectomy.</li><li>• OPSI is the most fatal complication</li><li>• left lower lobe atelectasis</li><li>• splenectomy.</li><li>• Post-splenectomy septicaemia may result from S. pneumoniae, Neisseria meningitides, Haemophilus influenzae or Escherichia coli . However, the risk is greater in the young patient, in splenectomised patients treated with chemoradiotherapy and in patients who have undergone splenectomy for thalassaemia, sickle cell disease and autoimmune anaemia or thrombocytopenia.</li><li>• S. pneumoniae, Neisseria meningitides, Haemophilus influenzae or Escherichia coli</li><li>• Opportunist/overwhelming post splenectomy infection (OPSI) is a major concern. Most infections after splenectomy could be avoided through measures that include offering the patients appropriate and timely immunization, antibiotic prophylaxis, education and prompt treatment of infection.</li><li>• The benefit of prophylactic antibiotics in this setting remains controversial. It is thought that children who have undergone splenectomy before the age of 5 years should be treated with a daily dose of penicillin until the age of 10 years. Prophylaxis in older children should be continued at least until the age of 16 years , but its use is less well defined in adults.</li><li>• undergone splenectomy before the age of 5 years should be treated with a daily dose of penicillin until the age of 10 years. Prophylaxis in older children should be continued at least until the age of 16 years</li><li>• Furthermore, compliance is problematic in the long term but, as the risk of overwhelming sepsis is greatest within the first 2–3 years after splenectomy, it seems reasonable to give prophylaxis during this time .</li><li>• as the risk of overwhelming sepsis is greatest within the first 2–3 years after splenectomy, it seems reasonable to give prophylaxis during this time</li><li>• Other complications:</li><li>• Other complications:</li><li>• Immediate complications specific to splenectomy include hemorrhage resulting from a slipped ligature, acute gastric dilation, injury to tail of pancreas and left basal atelectasis. Postoperative thrombocytosis may arise and, if the blood platelet count exceeds 10 Lac, prophylactic aspirin is recommended.</li><li>• Immediate complications specific to splenectomy include hemorrhage resulting from a slipped ligature, acute gastric dilation, injury to tail of pancreas and left basal atelectasis.</li><li>• Postoperative thrombocytosis may arise and, if the blood platelet count exceeds 10 Lac, prophylactic aspirin is recommended.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ Patients who have undergone a splenectomy face the highest risk of overwhelming post-splenectomy infection (OPSI) within the first 1 to 2 years following the procedure.</li><li>➤ undergone a splenectomy face the highest risk of overwhelming post-splenectomy infection</li><li>➤ first 1 to 2 years</li><li>➤ Ref : Bailey 28 th Ed. Pg 1230-31.</li><li>➤ Ref : Bailey 28 th Ed. Pg 1230-31.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Hypersplenism is a clinical syndrome that is characterised by splenic enlargement along with a combination of all except:", "options": [{"label": "A", "text": "Anemia", "correct": false}, {"label": "B", "text": "Bone marrow aplasia", "correct": true}, {"label": "C", "text": "Thrombocytopenia", "correct": false}, {"label": "D", "text": "Improvement after splenectomy", "correct": false}], "correct_answer": "B. Bone marrow aplasia", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B. Bone marrow aplasia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A : Anemia is a common feature of hypersplenism due to the sequestration and destruction of erythrocytes within the spleen .</li><li>• Option A</li><li>• Anemia</li><li>• hypersplenism</li><li>• sequestration and destruction</li><li>• erythrocytes within the spleen</li><li>• Option C : Thrombocytopenia , or low platelet count , is another hallmark of hypersplenism as the spleen sequesters and destroys platelets.</li><li>• Option C</li><li>• Thrombocytopenia</li><li>• low platelet count</li><li>• hypersplenism as the spleen sequesters and destroys platelets.</li><li>• Option D : Improvement after splenectomy Improvement after splenectomy is indicative of hypersplenism . When the spleen is removed, the symptoms like anemia and thrombocytopenia often improve as the excessive destruction of blood cells is mitigated.</li><li>• Option D</li><li>• Improvement after splenectomy Improvement</li><li>• splenectomy</li><li>• hypersplenism</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The incorrect statement regarding hypersplenism is that it is characterized by bone marrow aplasia (Option B). In fact, hypersplenism is associated with compensatory bone marrow hyperplasia and can improve with splenectomy.</li><li>➤ incorrect statement regarding hypersplenism</li><li>➤ characterized by bone marrow aplasia</li><li>➤ hypersplenism</li><li>➤ compensatory bone marrow hyperplasia</li><li>➤ improve with splenectomy.</li><li>➤ Hypersplenism is an indefinite clinical syndrome that is characterized by splenic enlargement , any combination of anaemia, leukopenia or thrombocytopenia, compensatory bone marrow hyperplasia and improvement after splenectomy. Careful clinical judgment is required to balance the long- and short-term risks of splenectomy against continued conservative management.</li><li>➤ Hypersplenism is an indefinite clinical syndrome that is characterized by splenic enlargement , any combination of anaemia, leukopenia or thrombocytopenia, compensatory bone marrow hyperplasia and improvement after splenectomy. Careful clinical judgment is required to balance the long- and short-term risks of splenectomy against continued conservative management.</li><li>➤ Hypersplenism is an indefinite clinical syndrome</li><li>➤ splenic enlargement</li><li>➤ combination of anaemia, leukopenia or thrombocytopenia,</li><li>➤ compensatory bone marrow hyperplasia</li><li>➤ improvement after splenectomy.</li><li>➤ Ref : Bailey 28 th Ed. Pg 1224</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 1224</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 25-year-old male has history of abdominal trauma, following which he underwent an emergency splenectomy. He now has high grade fever with sore throat and productive cough. Gram staining showed gram positive organisms in pairs. What’s the most likely causative agent?", "options": [{"label": "A", "text": "Staphylococcus aureus", "correct": false}, {"label": "B", "text": "Streptococcus pneumoniae", "correct": true}, {"label": "C", "text": "Haemophilus influenza", "correct": false}, {"label": "D", "text": "Neisseria gonorrhea", "correct": false}], "correct_answer": "B. Streptococcus pneumoniae", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B. Streptoccocus pneumoniae</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• The given clinical scenario is suggestive of infection with Streptococcus pneumonia following splenectomy .</li><li>• infection with Streptococcus pneumonia</li><li>• splenectomy</li><li>• Following splenectomy , the patients are more susceptible to infections with capsulated organisms . The commonly involved organisms are:</li><li>• splenectomy</li><li>• more susceptible to infections with capsulated organisms</li><li>• Streptococcus pneumonia (most common) Neisseria meningitides Haemophilus influenzae Escherichia coli</li><li>• Streptococcus pneumonia (most common)</li><li>• Neisseria meningitides</li><li>• Haemophilus influenzae</li><li>• Escherichia coli</li><li>• If elective splenectomy is planned, consideration should be given to vaccinating against pneumococcus, meningococcus C (both repeated every 5 years) and H. influenza type b (Hib) (repeated every 10 years). The last two vaccines are commonly delivered as a combined preparation. Yearly influenza vaccination has been recommended, as there is some evidence that it may reduce the risk of secondary bacterial infection. Such vaccinations should be administered at least 2 weeks before elective surgery or as soon as possible after recovery from surgery but before discharge from hospital.</li><li>• elective splenectomy</li><li>• vaccinating</li><li>• pneumococcus, meningococcus C</li><li>• H. influenza type b</li><li>• Such vaccinations should be administered at least 2 weeks before elective surgery or as soon as possible after recovery from surgery but before discharge from hospital.</li><li>• Ref : Bailey 28 th Ed. Pg 1231</li><li>• Ref : Bailey 28 th Ed. Pg 1231</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "What is the most common indication of splenectomy?", "options": [{"label": "A", "text": "Hemolytic anemia", "correct": false}, {"label": "B", "text": "Cancer of tail of pancreas", "correct": false}, {"label": "C", "text": "ITP", "correct": false}, {"label": "D", "text": "Splenic trauma", "correct": true}], "correct_answer": "D. Splenic trauma", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D. Splenic trauma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A : While splenectomy can be a treatment for hemolytic anemias like hereditary spherocytosis , it is not the most common indication for the surgery.</li><li>• Option A</li><li>• splenectomy can be a treatment for hemolytic anemias</li><li>• hereditary spherocytosis</li><li>• Option B : Cancer of Tail of Pancreas : Splenectomy may be performed as part of an en bloc resection when removing a cancer of the tail of the pancreas because of the anatomical proximity of the spleen to the pancreas . However, this is not the most frequent reason for splenectomy.</li><li>• Option B</li><li>• Cancer of Tail of Pancreas</li><li>• Splenectomy</li><li>• part of an en bloc resection</li><li>• removing a cancer of the tail of the pancreas</li><li>• anatomical proximity of the spleen to the pancreas</li><li>• Option C : Immune Thrombocytopenia (ITP): In ITP, the body's immune system attacks and destroys its own platelets . Splenectomy can be a treatment option for chronic ITP that doesn't respond to other treatments. It is a common indication but not the most frequent.</li><li>• Option C</li><li>• Immune Thrombocytopenia</li><li>• body's immune system attacks</li><li>• destroys its own platelets</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most common indication for splenectomy is splenic trauma , which can necessitate the removal of the spleen due to rupture or hemorrhage following an injury.</li><li>➤ common indication for splenectomy is splenic trauma</li><li>➤ necessitate the removal of the spleen</li><li>➤ rupture or hemorrhage</li><li>➤ Splenic trauma is the most common indication for splenectomy.</li><li>➤ Splenic trauma is the most common indication for splenectomy.</li><li>➤ Indications:</li><li>➤ Indications:</li><li>➤ Trauma Accidental Iatrogenic/Surgical</li><li>➤ Trauma Accidental Iatrogenic/Surgical</li><li>➤ Trauma</li><li>➤ Accidental Iatrogenic/Surgical</li><li>➤ Accidental</li><li>➤ Iatrogenic/Surgical</li><li>➤ Oncological Part of en bloc resection of CA tail of pancreas</li><li>➤ Oncological Part of en bloc resection of CA tail of pancreas</li><li>➤ Oncological</li><li>➤ Part of en bloc resection of CA tail of pancreas</li><li>➤ Part of en bloc resection of CA tail of pancreas</li><li>➤ Hematological Hereditary Spherocytosis Immune thrombocytopenia Purpura (ITP)</li><li>➤ Hematological Hereditary Spherocytosis Immune thrombocytopenia Purpura (ITP)</li><li>➤ Hematological</li><li>➤ Hereditary Spherocytosis Immune thrombocytopenia Purpura (ITP)</li><li>➤ Hereditary Spherocytosis</li><li>➤ Immune thrombocytopenia Purpura (ITP)</li><li>➤ Portal hypertension Hypersplenism</li><li>➤ Portal hypertension Hypersplenism</li><li>➤ Portal hypertension</li><li>➤ Hypersplenism</li><li>➤ Hypersplenism</li><li>➤ Ref : Bailey 28 th Ed. Pg 1229, box 70.2</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 1229, box 70.2</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is not a common site of porto-systemic anastomosis in portal hypertension?", "options": [{"label": "A", "text": "Superior rectal vein with middle rectal vein", "correct": false}, {"label": "B", "text": "Left gastric vein with IVC", "correct": true}, {"label": "C", "text": "Veins of ligamentum teres with superficial epigastric vein", "correct": false}, {"label": "D", "text": "Splenic vein with left renal vein", "correct": false}], "correct_answer": "B. Left gastric vein with IVC", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/screenshot-2024-03-28-183023.jpg"], "explanation": "<p><strong>Ans. B. Left gastric vein with IVC</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these shunts for portal hypertension is a selective shunt?", "options": [{"label": "A", "text": "Coronary vein to IVC", "correct": true}, {"label": "B", "text": "Side to side porto-caval shunt", "correct": false}, {"label": "C", "text": "Proximal splenorenal shunt", "correct": false}, {"label": "D", "text": "TIPSS", "correct": false}], "correct_answer": "A. Coronary vein to IVC", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/10_5z2Evm9.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/29/12_fI0xlgr.jpg"], "explanation": "<p><strong>Ans. A. Coronary vein to IVC.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• This is a selective shunt of Inokuchi .</li><li>• selective shunt of Inokuchi</li><li>• Nonselective shunts: Commonly used nonselective shunts , all of which completely divert portal flow , include:</li><li>• Nonselective shunts:</li><li>• nonselective shunts</li><li>• completely divert portal flow</li><li>• The end-to-side portacaval shunt (Eck fistula) Side-to-side portacaval shunt, Large-diameter interposition shunts Conventional splenorenal shunt/Proximal splenorenal shunt (Linton) TIPS, also a non-selective shunt, is the preferred therapy for most situations in which nonselective shunts were previously used.</li><li>• The end-to-side portacaval shunt (Eck fistula)</li><li>• Side-to-side portacaval shunt,</li><li>• Large-diameter interposition shunts</li><li>• Conventional splenorenal shunt/Proximal splenorenal shunt (Linton)</li><li>• TIPS, also a non-selective shunt, is the preferred therapy for most situations in which nonselective shunts were previously used.</li><li>• Presently, non- selective shunts are only rarely indicated. Because they completely divert portal flow , like the end-to-side portacaval shunt , however, side-to-side shunts also accelerate hepatic failure and lead to frequent post-shunt encephalopathy.</li><li>• non- selective shunts</li><li>• rarely indicated.</li><li>• completely divert portal flow</li><li>• end-to-side portacaval shunt</li><li>• side-to-side shunts</li><li>• accelerate hepatic failure</li><li>• frequent post-shunt encephalopathy.</li><li>• Selective shunts :</li><li>• Selective shunts</li><li>• Distal splenorenal shunt (Warren) Inokuchi shunt between left gastric (coronary) vein and IVC.</li><li>• Distal splenorenal shunt (Warren)</li><li>• Inokuchi shunt between left gastric (coronary) vein and IVC.</li><li>• Inokuchi shunt between left gastric (coronary) vein and IVC.</li><li>• Ref : Sabiston textbook of surgery 21 st Ed., Pg 1448-1450.</li><li>• Ref</li><li>• : Sabiston textbook of surgery 21 st Ed., Pg 1448-1450.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is the most common cause of portal hypertension world-wide?", "options": [{"label": "A", "text": "Cirrhosis", "correct": true}, {"label": "B", "text": "Non-cirrhotic portal fibrosis", "correct": false}, {"label": "C", "text": "Portal vein thrombosis", "correct": false}, {"label": "D", "text": "Budd Chiari syndrome", "correct": false}], "correct_answer": "A. Cirrhosis", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A Cirrhosis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Portal hypertension is most commonly due to liver cirrhosis , although it also occurs with extrahepatic portal vein occlusion , intrahepatic veno-occlusive disease and occlusion of the main hepatic veins (Budd–Chiari syndrome).</li><li>• Portal hypertension</li><li>• liver cirrhosis</li><li>• also occurs with extrahepatic portal vein occlusion</li><li>• intrahepatic veno-occlusive disease</li><li>• occlusion of the main hepatic veins</li><li>• Ref : Bailey 28 th ed. Pg 1203.</li><li>• Ref : Bailey 28 th ed. Pg 1203.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}]; if (!Array.isArray(questions) || questions.length === 0) { throw new Error("Questions data is empty or invalid"); } debugLog(`Successfully parsed ${questions.length} questions`); } catch (e) { console.error("Failed to parse questions_json:", e); document.getElementById('error-message').innerHTML = "Error loading quiz data. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('start-test').disabled = true; // Fallback to sample questions for testing questions = [ { text: "What is 2 + 2?", options: [ { label: "A", text: "3", correct: false }, { label: "B", text: "4", correct: true }, { label: "C", text: "5", correct: false }, { label: "D", text: "6", correct: false } ], correct_answer: "B. 4", question_images: [], explanation_images: [], explanation: "<p>2 + 2 = 4</p><p>@dams_new_robot</p>", bot: "@dams_new_robot", audio: "", video: "" } ]; debugLog("Loaded fallback questions"); } // Quiz state let currentQuestion = 0; let answers = new Array(questions.length).fill(null); let markedForReview = new Array(questions.length).fill(false); let timeRemaining = 114 * 60; // Duration in seconds let timerInterval = null; const quizId = `{title.replace(/\s+/g, '_').toLowerCase()}`; // Unique ID for local storage // Load saved progress function loadProgress() { try { debugLog("Loading progress from localStorage"); const saved = localStorage.getItem(`quiz_${quizId}`); if (saved) { const { savedAnswers, savedMarked, savedTime } = JSON.parse(saved); answers = savedAnswers || answers; markedForReview = savedMarked || markedForReview; timeRemaining = savedTime !== undefined ? savedTime : timeRemaining; debugLog("Progress loaded successfully"); } else { debugLog("No saved progress found"); } } catch (e) { console.error("Error loading progress:", e); debugLog("Failed to load progress: " + e.message); } } // Save progress function saveProgress() { try { debugLog("Saving progress to localStorage"); localStorage.setItem(`quiz_${quizId}`, JSON.stringify({ savedAnswers: answers, savedMarked: markedForReview, savedTime: timeRemaining })); debugLog("Progress saved successfully"); } catch (e) { console.error("Error saving progress:", e); debugLog("Failed to save progress: " + e.message); } } // Initialize quiz function initQuiz() { try { debugLog("Initializing quiz"); loadProgress(); const startButton = document.getElementById('start-test'); if (!startButton) { throw new Error("Start test button not found"); } startButton.addEventListener('click', startQuiz); debugLog("Start test button listener attached"); document.getElementById('previous-btn').addEventListener('click', showPreviousQuestion); document.getElementById('next-btn').addEventListener('click', showNextQuestion); document.getElementById('mark-review').addEventListener('click', toggleMarkForReview); document.getElementById('nav-toggle').addEventListener('click', toggleNavPanel); document.getElementById('submit-test').addEventListener('click', showSubmitModal); document.getElementById('continue-test').addEventListener('click', closeExitModal); document.getElementById('exit-test').addEventListener('click', () => { debugLog("Exiting test"); localStorage.removeItem(`quiz_${quizId}`); window.location.reload(); }); document.getElementById('cancel-submit').addEventListener('click', closeSubmitModal); document.getElementById('confirm-submit').addEventListener('click', submitTest); document.getElementById('take-again').addEventListener('click', () => { debugLog("Restarting test"); localStorage.removeItem(`quiz_${quizId}`); window.location.reload(); }); document.getElementById('review-test').addEventListener('click', () => showResults(currentResultQuestion)); document.getElementById('close-nav').addEventListener('click', toggleNavPanel); document.getElementById('theme-toggle').addEventListener('click', toggleTheme); document.getElementById('nav-filter').addEventListener('change', updateNavPanel); document.getElementById('prev-result').addEventListener('click', showPreviousResult); document.getElementById('next-result').addEventListener('click', showNextResult); document.getElementById('results-nav-toggle').addEventListener('click', toggleResultsNavPanel); document.getElementById('close-results-nav').addEventListener('click', toggleResultsNavPanel); document.getElementById('results-nav-filter').addEventListener('change', updateResultsNavPanel); debugLog("Quiz initialized successfully"); } catch (e) { console.error("Failed to initialize quiz:", e); debugLog("Failed to initialize quiz: " + e.message); document.getElementById('error-message').innerHTML = "Error initializing quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('start-test').disabled = true; } } // Start quiz function startQuiz() { try { debugLog("Starting quiz"); document.getElementById('instructions').classList.add('hidden'); document.getElementById('quiz').classList.remove('hidden'); showQuestion(currentQuestion); startTimer(); updateNavPanel(); debugLog("Quiz started successfully"); } catch (e) { console.error("Error starting quiz:", e); debugLog("Failed to start quiz: " + e.message); document.getElementById('error-message').innerHTML = "Error starting quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('quiz').classList.add('hidden'); document.getElementById('instructions').classList.remove('hidden'); } } // Show question function showQuestion(index) { try { debugLog(`Showing question ${index + 1}`); currentQuestion = index; const q = questions[index]; if (!q) { throw new Error(`Question ${index} is undefined`); } document.getElementById('question-number').innerHTML = `Question <span>${index + 1}</span> of ${questions.length}`; document.getElementById('question-text').innerHTML = q.text || "No question text available"; const imagesDiv = document.getElementById('question-images'); imagesDiv.innerHTML = q.question_images && q.question_images.length > 0 ? q.question_images.map(url => `<img src="${url}" alt="Question Image" class="max-w-full h-auto rounded-lg">`).join('') : ''; const optionsDiv = document.getElementById('options'); optionsDiv.innerHTML = q.options && q.options.length > 0 ? q.options.map(opt => ` <button class="option-btn w-full text-left p-3 border rounded-lg ${answers[index] === opt.label ? 'selected' : ''}" onclick="selectOption(${index}, '${opt.label}')" aria-label="Option ${opt.label}: ${opt.text}"> ${opt.label}. ${opt.text} </button> `).join('') : '<p class="text-red-500">No options available</p>'; document.getElementById('previous-btn').disabled = index === 0; document.getElementById('next-btn').disabled = index === questions.length - 1; document.getElementById('mark-review').classList.toggle('marked', markedForReview[index]); updateProgressBar(); saveProgress(); window.scrollTo({ top: 0, behavior: 'smooth' }); debugLog(`Question ${index + 1} displayed successfully`); } catch (e) { console.error("Error displaying question:", e); debugLog("Failed to display question: " + e.message); } } // Select option function selectOption(index, label) { try { debugLog(`Selecting option ${label} for question ${index + 1}`); answers[index] = label; const optionsDiv = document.getElementById('options'); const optionButtons = optionsDiv.querySelectorAll('.option-btn'); optionButtons.forEach(btn => { const btnLabel = btn.textContent.trim().split('.')[0]; btn.classList.toggle('selected', btnLabel === label); }); updateNavPanel(); saveProgress(); debugLog(`Option ${label} selected for question ${index + 1}`); } catch (e) { console.error("Error selecting option:", e); debugLog("Failed to select option: " + e.message); } } // Toggle mark for review function toggleMarkForReview() { try { debugLog(`Toggling mark for review on question ${currentQuestion + 1}`); markedForReview[currentQuestion] = !markedForReview[currentQuestion]; document.getElementById('mark-review').classList.toggle('marked', markedForReview[currentQuestion]); updateNavPanel(); saveProgress(); debugLog(`Mark for review toggled for question ${currentQuestion + 1}`); } catch (e) { console.error("Error marking for review:", e); debugLog("Failed to mark for review: " + e.message); } } // Navigate to previous question function showPreviousQuestion() { try { debugLog(`Navigating to previous question from ${currentQuestion + 1}`); if (currentQuestion > 0) { currentQuestion--; showQuestion(currentQuestion); } } catch (e) { console.error("Error navigating to previous question:", e); debugLog("Failed to navigate to previous question: " + e.message); } } // Navigate to next question function showNextQuestion() { try { debugLog(`Navigating to next question from ${currentQuestion + 1}`); if (currentQuestion < questions.length - 1) { currentQuestion++; showQuestion(currentQuestion); } } catch (e) { console.error("Error navigating to next question:", e); debugLog("Failed to navigate to next question: " + e.message); } } // Handle question navigation click function handleQuestionNavClick(index) { try { debugLog(`Navigating to question ${index + 1} via nav panel`); showQuestion(index); toggleNavPanel(); } catch (e) { console.error("Error handling navigation click:", e); debugLog("Failed to navigate via nav panel: " + e.message); } } // Start timer function startTimer() { try { debugLog("Starting timer"); timerInterval = setInterval(() => { if (timeRemaining <= 0) { debugLog("Timer expired, submitting test"); clearInterval(timerInterval); submitTest(); } else { timeRemaining--; const minutes = Math.floor(timeRemaining / 60); const seconds = timeRemaining % 60; document.getElementById('timer').innerHTML = `Time Remaining: <span>${minutes.toString().padStart(2, '0')}:${seconds.toString().padStart(2, '0')}</span>`; saveProgress(); } }, 1000); debugLog("Timer started successfully"); } catch (e) { console.error("Error starting timer:", e); debugLog("Failed to start timer: " + e.message); } } // Update progress bar function updateProgressBar() { try { debugLog("Updating progress bar"); const progress = ((currentQuestion + 1) / questions.length) * 100; document.getElementById('progress-bar').style.width = `${progress}%`; debugLog("Progress bar updated"); } catch (e) { console.error("Error updating progress bar:", e); debugLog("Failed to update progress bar: " + e.message); } } // Update quiz navigation panel function updateNavPanel() { try { debugLog("Updating quiz navigation panel"); const filter = document.getElementById('nav-filter').value; const navGrid = document.getElementById('nav-grid'); navGrid.innerHTML = questions.map((_, i) => { if (filter === 'answered' && !answers[i]) return ''; if (filter === 'unanswered' && answers[i]) return ''; if (filter === 'marked' && !markedForReview[i]) return ''; return ` <button class="question-nav-btn ${answers[i] ? 'answered' : 'unanswered'} ${markedForReview[i] ? 'marked-nav' : ''}" onclick="handleQuestionNavClick(${i})" aria-label="Go to Question ${i + 1}"> ${i + 1} </button> `; }).join(''); debugLog("Quiz navigation panel updated"); } catch (e) { console.error("Error updating quiz navigation panel:", e); debugLog("Failed to update quiz navigation panel: " + e.message); } } // Update results navigation panel function updateResultsNavPanel() { try { debugLog("Updating results navigation panel"); const filter = document.getElementById('results-nav-filter').value; const navGrid = document.getElementById('results-nav-grid'); navGrid.innerHTML = questions.map((_, i) => { if (filter === 'answered' && !answers[i]) return ''; if (filter === 'unanswered' && answers[i]) return ''; if (filter === 'marked' && !markedForReview[i]) return ''; return ` <button class="result-nav-btn-grid ${answers[i] ? 'answered' : 'unanswered'} ${markedForReview[i] ? 'marked-nav' : ''}" onclick="handleResultNavClick(${i})" aria-label="Go to Result for Question ${i + 1}"> ${i + 1} </button> `; }).join(''); debugLog("Results navigation panel updated"); } catch (e) { console.error("Error updating results navigation panel:", e); debugLog("Failed to update results navigation panel: " + e.message); } } // Toggle quiz navigation panel function toggleNavPanel() { try { debugLog("Toggling quiz navigation panel"); const navPanel = document.getElementById('nav-panel'); navPanel.classList.toggle('hidden'); debugLog("Quiz navigation panel toggled"); } catch (e) { console.error("Error toggling quiz navigation panel:", e); debugLog("Failed to toggle quiz navigation panel: " + e.message); } } // Toggle results navigation panel function toggleResultsNavPanel() { try { debugLog("Toggling results navigation panel"); const resultsNavPanel = document.getElementById('results-nav-panel'); resultsNavPanel.classList.toggle('hidden'); if (!resultsNavPanel.classList.contains('hidden')) { updateResultsNavPanel(); } debugLog("Results navigation panel toggled"); } catch (e) { console.error("Error toggling results navigation panel:", e); debugLog("Failed to toggle results navigation panel: " + e.message); } } // Handle result navigation click function handleResultNavClick(index) { try { debugLog(`Navigating to result for question ${index + 1} via nav panel`); showResults(index); toggleResultsNavPanel(); } catch (e) { console.error("Error handling result navigation click:", e); debugLog("Failed to navigate to result: " + e.message); } } // Show submit modal function showSubmitModal() { try { debugLog("Showing submit modal"); const attempted = answers.filter(a => a !== null).length; document.getElementById('attempted-count').textContent = attempted; document.getElementById('unattempted-count').textContent = questions.length - attempted; document.getElementById('submit-modal').classList.remove('hidden'); debugLog("Submit modal displayed"); } catch (e) { console.error("Error showing submit modal:", e); debugLog("Failed to show submit modal: " + e.message); } } // Close submit modal function closeSubmitModal() { try { debugLog("Closing submit modal"); document.getElementById('submit-modal').classList.add('hidden'); debugLog("Submit modal closed"); } catch (e) { console.error("Error closing submit modal:", e); debugLog("Failed to close submit modal: " + e.message); } } // Close exit modal function closeExitModal() { try { debugLog("Closing exit modal"); document.getElementById('exit-modal').classList.add('hidden'); debugLog("Exit modal closed"); } catch (e) { console.error("Error closing exit modal:", e); debugLog("Failed to close exit modal: " + e.message); } } // Submit test function submitTest() { try { debugLog("Submitting test"); clearInterval(timerInterval); document.getElementById('quiz').classList.add('hidden'); document.getElementById('submit-modal').classList.add('hidden'); document.getElementById('results').classList.remove('hidden'); showResults(0); // Start with first question // Trigger confetti animation confetti({ particleCount: 100, spread: 70, origin: { y: 0.6 } }); localStorage.removeItem(`quiz_${quizId}`); debugLog("Test submitted successfully"); } catch (e) { console.error("Error submitting test:", e); debugLog("Failed to submit test: " + e.message); } } // Show result for a single question function showResults(index) { try { debugLog(`Showing result for question ${index + 1}`); currentResultQuestion = index; let correct = 0, wrong = 0, unanswered = 0, marked = 0; answers.forEach((answer, i) => { const isCorrect = answer && questions[i].options.find(opt => opt.label === answer)?.correct; if (answer === null) unanswered++; else if (isCorrect) correct++; else wrong++; if (markedForReview[i]) marked++; }); const q = questions[index]; if (!q) { throw new Error(`Question ${index} is undefined`); } const userAnswer = answers[index]; const isCorrect = userAnswer && q.options.find(opt => opt.label === userAnswer)?.correct; const resultsContent = document.getElementById('results-content'); resultsContent.innerHTML = ` <div class="border p-4 rounded-lg ${isCorrect ? 'bg-green-50' : userAnswer ? 'bg-red-50' : 'bg-gray-50'}"> <p class="font-semibold">Question ${index + 1}: ${q.text || 'No question text'}</p> ${q.question_images && q.question_images.length > 0 ? q.question_images.map(url => `<img src="${url}" alt="Question Image" class="max-w-full h-auto rounded-lg my-2">`).join('') : ''} <p><strong>Your Answer:</strong> ${userAnswer ? `${userAnswer}. ${q.options.find(opt => opt.label === userAnswer)?.text || 'Invalid option'}` : 'Unanswered'}</p> <p><strong>Correct Answer:</strong> ${q.correct_answer || 'Unknown'}</p> <div class="mt-2">${q.explanation || 'No explanation available'}</div> ${q.explanation_images && q.explanation_images.length > 0 ? q.explanation_images.map(url => `<img src="${url}" alt="Explanation Image" class="max-w-full h-auto rounded-lg my-2">`).join('') : ''} ${q.video ? ` <button class="play-video bg-blue-500 text-white px-4 py-2 rounded-lg mt-2" onclick="loadVideo(this, '${q.video}', 'video-${index}')" aria-label="Play explanation video for Question ${index + 1}"> Play Video Explanation </button> <div id="video-${index}" class="video-container mt-2"></div> ` : '<p class="text-gray-500 mt-2">No video available</p>'} ${q.audio ? ` <button class="play-audio bg-blue-500 text-white px-4 py-2 rounded-lg mt-2" onclick="loadAudio(this, '${q.audio}', 'audio-${index}')" aria-label="Play audio explanation for Question ${index + 1}"> Play Audio Explanation </button> <div id="audio-${index}" class="audio-container mt-2"></div> ` : ''} </div> `; document.getElementById('correct-count').textContent = correct; document.getElementById('wrong-count').textContent = wrong; document.getElementById('unanswered-count').textContent = unanswered; document.getElementById('marked-count').textContent = marked; document.getElementById('result-question-number').innerHTML = `Question <span>${index + 1}</span> of ${questions.length}`; document.getElementById('prev-result').disabled = index === 0; document.getElementById('next-result').disabled = index === questions.length - 1; updateResultsNavPanel(); window.scrollTo({ top: 0, behavior: 'smooth' }); debugLog(`Result for question ${index + 1} displayed successfully`); } catch (e) { console.error("Error displaying result:", e); debugLog("Failed to display result: " + e.message); } } // Navigate to previous result function showPreviousResult() { try { debugLog(`Navigating to previous result from question ${currentResultQuestion + 1}`); if (currentResultQuestion > 0) { showResults(currentResultQuestion - 1); } } catch (e) { console.error("Error navigating to previous result:", e); debugLog("Failed to navigate to previous result: " + e.message); } } // Navigate to next result function showNextResult() { try { debugLog(`Navigating to next result from question ${currentResultQuestion + 1}`); if (currentResultQuestion < questions.length - 1) { showResults(currentResultQuestion + 1); } } catch (e) { console.error("Error navigating to next result:", e); debugLog("Failed to navigate to next result: " + e.message); } } // Lazy-load video function loadVideo(button, videoUrl, containerId) { try { debugLog(`Loading video for ${containerId}: ${videoUrl}`); if (!videoUrl) { const container = document.getElementById(containerId); container.innerHTML = `<p class="text-gray-500">No video available</p>`; button.remove(); debugLog("No video URL provided"); return; } const container = document.getElementById(containerId); container.innerHTML = ` <div class="video-loading"></div> <video controls class="w-full max-w-[600px] rounded-lg" preload="metadata" aria-label="Video explanation"> <source src="${videoUrl}" type="${videoUrl.endsWith('.m3u8') ? 'application/x-mpegURL' : 'video/mp4'}"> Your browser does not support the video tag. </video> `; container.classList.add('active'); button.remove(); // Initialize HLS.js for .m3u8 videos const video = container.querySelector('video'); if (videoUrl.endsWith('.m3u8') && Hls.isSupported()) { const hls = new Hls(); hls.loadSource(videoUrl); hls.attachMedia(video); hls.on(Hls.Events.ERROR, (event, data) => { console.error("HLS.js error:", data); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; debugLog("HLS.js error: " + JSON.stringify(data)); }); } else if (videoUrl.endsWith('.m3u8') && video.canPlayType('application/vnd.apple.mpegurl')) { video.src = videoUrl; } // Handle video load errors video.onerror = () => { console.error("Video load error for URL:", videoUrl); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; debugLog("Video load error for URL: " + videoUrl); }; // Remove loading spinner when video is ready video.onloadedmetadata = () => { container.querySelector('.video-loading').remove(); debugLog("Video loaded successfully"); }; } catch (e) { console.error("Error loading video:", e); debugLog("Failed to load video: " + e.message); const container = document.getElementById(containerId); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; } } // Lazy-load audio function loadAudio(button, audioUrl, containerId) { try { debugLog(`Loading audio for ${containerId}: ${audioUrl}`); if (!audioUrl) { const container = document.getElementById(containerId); container.innerHTML = `<p class="text-gray-500">No audio available</p>`; button.remove(); debugLog("No audio URL provided"); return; } const container = document.getElementById(containerId); container.innerHTML = ` <audio controls class="w-full max-w-[600px]" preload="metadata" aria-label="Audio explanation"> <source src="${audioUrl}" type="audio/mpeg"> Your browser does not support the audio tag. </audio> `; container.classList.add('active'); button.remove(); // Handle audio load errors const audio = container.querySelector('audio'); audio.onerror = () => { console.error("Audio load error for URL:", audioUrl); container.innerHTML = `<p class="text-red-500">Error loading audio. <a href="${audioUrl}" target="_blank" aria-label="Open audio in new tab">Open audio</a></p>`; debugLog("Audio load error for URL: " + audioUrl); }; debugLog("Audio loaded successfully"); } catch (e) { console.error("Error loading audio:", e); debugLog("Failed to load audio: " + e.message); const container = document.getElementById(containerId); container.innerHTML = `<p class="text-red-500">Error loading audio. <a href="${audioUrl}" target="_blank" aria-label="Open audio in new tab">Open audio</a></p>`; } } // Toggle dark mode function toggleTheme() { try { debugLog("Toggling theme"); document.documentElement.classList.toggle('dark'); localStorage.setItem('theme', document.documentElement.classList.contains('dark') ? 'dark' : 'light'); debugLog("Theme toggled successfully"); } catch (e) { console.error("Error toggling theme:", e); debugLog("Failed to toggle theme: " + e.message); } } // Load theme preference function loadTheme() { try { debugLog("Loading theme preference"); const theme = localStorage.getItem('theme'); if (theme === 'dark') { document.documentElement.classList.add('dark'); } debugLog("Theme loaded successfully"); } catch (e) { console.error("Error loading theme:", e); debugLog("Failed to load theme: " + e.message); } } // Initialize on DOM content loaded window.addEventListener('DOMContentLoaded', () => { try { debugLog("DOM content loaded, initializing quiz"); loadTheme(); initQuiz(); } catch (e) { console.error("Error during DOMContentLoaded:", e); debugLog("Failed to initialize on DOMContentLoaded: " + e.message); document.getElementById('error-message').innerHTML = "Error initializing quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); } }); </script> </body> </html>" frameborder="0" width="100%" height="2000px">
<div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <h2 class="text-xl font-semibold mb-4">Instructions</h2> <h4 class="text-gray-800 text-lg font-semibold mt-6 mb-4">Test Features:</h4> <ul class="space-y-3"> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Multiple choice questions with single correct answers </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Timer-based testing for realistic exam conditions </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Mark questions for review functionality </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Comprehensive results and performance analysis </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Mobile-optimized interface for learning on-the-go </li> </ul> <div class="mt-6 flex space-x-4 button-group md:flex-row flex-col"> <button class="bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="start-test">Start Test</button> </div> <div class="error-message hidden" id="error-message"></div> </div> </section> <!-- Quiz Section --> <section class="container mx-auto px-4 md:px-6 pt-4 md:pt-6 pb-1 hidden section-transition" id="quiz"> <div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <!-- Progress Bar --> <div class="w-full bg-gray-200 rounded-full h-3 mb-4"> <div class="progress-bar h-3 rounded-full" id="progress-bar" style="width: 0%"></div> </div> <!-- Question Header --> <div class="flex flex-col md:flex-row justify-between items-center mb-4"> <h2 class="text-lg font-semibold" id="question-number">Question <span>1</span> of 4</h2> <p class="text-lg font-semibold mt-2 md:mt-0" id="timer">Time Remaining: <span>00:00</span></p> </div> <!-- Question Content --> <div class="mb-6" id="question-content"> <p class="text-gray-800 mb-4" id="question-text"></p> <div class="flex flex-wrap gap-4 mb-4" id="question-images"></div> <div class="space-y-3" id="options"></div> </div> <!-- Navigation Buttons --> <div class="flex flex-col md:flex-row justify-between items-center gap-2 md:gap-4"> <div class="flex gap-2 w-full md:w-auto"> <button class="bg-[#2c5281] text-white px-4 py-3 w-full md:w-32 h-14 rounded-lg hover:bg-[#2c5281] transition" disabled="" id="previous-btn">Previous</button> <button class="bg-[#2c5281] text-white px-4 py-3 w-full md:w-32 h-14 rounded-lg hover:bg-[#2c5281] transition" id="next-btn">Next</button> </div> <div class="flex items-center gap-2"> <button class="bg-transparent text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-100 transition flex items-center gap-1" id="mark-review"> Review <svg xmlns="http://www.w3.org/2000/svg" class="h-5 w-5" viewBox="0 0 20 20" fill="currentColor"> <path d="M10 2a1 1 0 00-1 1v14l3.293-3.293a1 1 0 011.414 0L17 17V3a1 1 0 00-1-1H10z" /> </svg> </button> <button class="bg-transparent text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-100 transition flex items-center gap-1" id="nav-toggle"> Question 🧭 </button> <button class="bg-green-500 text-white px-6 py-3 w-44 h-14 rounded-lg hover:bg-green-600 transition w-full md:w-auto" id="submit-test">Submit Test</button> </div> </div> </section> <!-- Results Section --> <section class="container mx-auto px-4 md:px-6 pt-4 md:pt-6 pb-1 hidden section-transition" id="results"> <div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <h2 class="text-2xl font-semibold mb-4">Anaesthesia Machine - Results</h2> <div class="grid grid-cols-1 md:grid-cols-2 gap-4 mb-6"> <p><strong>Correct:</strong> <span id="correct-count" class="text-[#000000]">0</span></p> <p><strong>Wrong:</strong> <span id="wrong-count" class="text-[#000000]">0</span></p> <p><strong>Unanswered:</strong> <span id="unanswered-count" class="text-[#000000]-500">0</span></p> <p><strong>Marked for Review:</strong> <span id="marked-count" class="text-[#000000]">0</span></p> </div> <h3 class="text-lg font-semibold mb-4" id="result-question-number">Question <span>1</span> of 4</h3> <div class="space-y-6" id="results-content"></div> <div class="result-nav"> <button aria-label="Previous question result" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" disabled="" id="prev-result">Previous</button> <button aria-label="Toggle results navigation panel" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="results-nav-toggle">Result 🧭</button> <button aria-label="Next question result" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="next-result">Next</button> </div> <div class="mt-6 flex space-x-4 button-group md:flex-row flex-col"> <button class="bg-green-500 text-white px-6 py-2 rounded-lg hover:bg-green-600 transition" id="take-again">Take Again</button> </div> </div> </section> <!-- Exit Confirmation Modal --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 hidden" id="exit-modal" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white rounded-lg p-6 max-w-sm w-full"> <h2 class="text-xl font-semibold mb-4">Leave Test?</h2> <p class="text-gray-700 mb-4">Your progress will be lost if you leave this page. Are you sure you want to exit?</p> <div class="flex justify-end space-x-4"> <button class="bg-gray-300 text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-400 transition" id="continue-test">No, Continue</button> <button class="bg-red-500 text-white px-4 py-2 rounded-lg hover:bg-red-600 transition" id="exit-test">Yes, Exit</button> </div> </div> </div> <!-- Submit Confirmation Modal --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 hidden" id="submit-modal" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white rounded-lg p-6 max-w-sm w-full"> <h2 class="text-xl font-semibold mb-4">Confirm Submission</h2> <p class="text-gray-700 mb-2">You have attempted <span id="attempted-count">0</span> of 4 questions.</p> <p class="text-gray-700 mb-4"><span id="unattempted-count">0</span> questions are unattempted.</p> <div class="flex justify-end space-x-4"> <button class="bg-gray-300 text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-400 transition" id="cancel-submit">Cancel</button> <button class="text-white px-4 py-2 rounded-lg hover:bg-[#1a365d] transition" style="background-color: #2c5281;" id="confirm-submit">Submit Test</button> </div> </div> </div> <!-- Quiz Navigation Panel --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 z-50 nav-panel hidden overflow-y-auto" id="nav-panel" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white shadow-lg p-4 rounded-lg w-full max-w-2xl max-h-[80vh] overflow-y-auto"> <h2 class="text-lg font-semibold mb-4">Questions Navigation</h2> <div class="mb-4"> <select class="w-full p-2 border rounded-lg text-gray-700" id="nav-filter"> <option value="all">All Questions</option> <option value="answered">Answered</option> <option value="unanswered">Unanswered</option> <option value="marked">Marked for Review</option> </select> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-nav">Close</button> </div> </div> <!-- Results Navigation Panel --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 z-50 results-nav-panel hidden overflow-y-auto" id="results-nav-panel" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white shadow-lg p-4 rounded-lg w-full max-w-2xl max-h-[80vh] overflow-y-auto"> <h2 class="text-lg font-semibold mb-4">Results Navigation</h2> <div class="mb-4"> <select class="w-full p-2 border rounded-lg text-gray-700" id="results-nav-filter"> <option value="all">All Questions</option> <option value="answered">Answered</option> <option value="unanswered">Unanswered</option> <option value="marked">Marked for Review</option> </select> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="results-nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-results-nav">Close</button> </div> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="results-nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-results-nav">Close</button> </div> <!-- JavaScript Logic --> <script> // Enable debug mode for detailed logging const DEBUG_MODE = true; // Log debug messages function debugLog(message) { if (DEBUG_MODE) { console.log(`[DEBUG] ${message}`); } } // Initialize questions with error handling let questions = []; let currentResultQuestion = 0; // State for current question in results try { debugLog("Attempting to parse questions_json"); questions = [{"text": "A 35 years old female patient has a BMI of 36 kg/m 2 . She has multiple comorbidities and hence presented to the bariatric surgeon for surgical options to lose weight. Which of the below parameters will make her unfit for surgery?", "options": [{"label": "A", "text": "Coronary Artery Disease", "correct": false}, {"label": "B", "text": "Her BMI is below the Cut off for Surgery", "correct": false}, {"label": "C", "text": "Capable of Understanding Lifestyle Changes", "correct": false}, {"label": "D", "text": "Severe Depression", "correct": true}], "correct_answer": "D. Severe Depression", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/30/screenshot-2023-12-30-175730.jpg"], "explanation": "<p><strong>Ans. D) Severe Depression</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Let's evaluate all the options to identify which parameter would make a 35-year-old female patient with a BMI of 36 kg/m^2 unfit for bariatric surgery:</li><li>• Option A. Coronary artery disease is a significant comorbidity that needs to be well-managed before bariatric surgery, but it does not necessarily make a patient unfit for surgery if optimized. In fact, it is one of the co-morbidities which can be considered as an indication .</li><li>• Option A.</li><li>• significant comorbidity</li><li>• well-managed</li><li>• indication</li><li>• Option B . A BMI below the cut-off for surgery could make a patient ineligible for bariatric surgery. However, a BMI of 36 kg/m^2 is above the typical cut-off of 35 kg/m^2 with comorbidities or 40 kg/m^2 without comorbidities.</li><li>• Option B</li><li>• patient ineligible</li><li>• Option C . Being capable of understanding lifestyle changes is a necessary criterion for suitability for bariatric surgery, not a disqualifying one.</li><li>• Option C</li><li>• understanding lifestyle changes</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Severe depression can make a patient unfit for bariatric surgery because it may affect their ability to understand and comply with the significant lifestyle changes required postoperatively .</li><li>➤ patient unfit</li><li>➤ affect their ability</li><li>➤ understand</li><li>➤ comply with</li><li>➤ significant lifestyle changes</li><li>➤ required postoperatively</li><li>➤ Ref : Bailey and Love, 28 th Ed., Pg 1184</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed., Pg 1184</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is not a bariatric surgery?", "options": [{"label": "A", "text": "Roux-en-Y Gastrojejunostomy", "correct": false}, {"label": "B", "text": "Sleeve Gastrectomy", "correct": false}, {"label": "C", "text": "Pyloric Exclusion with Gastrojejunostomy", "correct": true}, {"label": "D", "text": "Laparoscopic Gastric Banding", "correct": false}], "correct_answer": "C. Pyloric Exclusion with Gastrojejunostomy", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/30/picture17_8K7nX0K.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/30/picture18_BtMblDG.jpg"], "explanation": "<p><strong>Ans. C) Pyloric Exclusion with Gastrojejunostomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A . Roux-en-Y gastrojejunostomy is a common form of bariatric surgery that is both restrictive and malabsorptive . It involves creating a small stomach pouch and connecting it directly to the jejunum .</li><li>• Option A</li><li>• common form</li><li>• both restrictive</li><li>• malabsorptive</li><li>• creating</li><li>• small stomach pouch</li><li>• directly</li><li>• jejunum</li><li>• Option B . Sleeve gastrectomy is a restrictive bariatric surgery where a portion of the stomach is removed , leaving a smaller , tube-shaped stomach .</li><li>• Option B</li><li>• restrictive bariatric surgery</li><li>• removed</li><li>• smaller</li><li>• tube-shaped stomach</li><li>• Option D. Laparoscopic gastric banding is a restrictive bariatric surgery that involves placing an adjustable band around the upper portion of the stomach to create a small stomach pouch .</li><li>• Option D.</li><li>• restrictive bariatric surgery</li><li>• placing</li><li>• adjustable band</li><li>• upper portion</li><li>• stomach</li><li>• small stomach pouch</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Pyloric exclusion with gastrojejunostomy is not a bariatric surgery; it is a technique used to repair duodenal and pancreatic injuries . Bariatric surgeries are primarily aimed at weight loss and include restrictive , malabsorptive , combined procedures , and endoscopic bariatric procedures.</li><li>➤ technique used</li><li>➤ repair duodenal</li><li>➤ pancreatic injuries</li><li>➤ weight loss</li><li>➤ restrictive</li><li>➤ malabsorptive</li><li>➤ combined procedures</li><li>➤ endoscopic bariatric procedures.</li><li>➤ Types of Bariatric procedures:</li><li>➤ Types of Bariatric procedures:</li><li>➤ Restrictive: Where stomach is reduced in size à reduction in meal size à lower calorie intake à Weight loss.</li><li>➤ Restrictive: Where stomach is reduced in size à reduction in meal size à lower calorie intake à Weight loss.</li><li>➤ Restrictive:</li><li>➤ Examples: Sleeve gastrectomy, adjustable gastric band</li><li>➤ Examples:</li><li>➤ Malabsorptive: Where segment of intestine is bypassed à less absorptive area à Lesser absorption of food à weight loss.</li><li>➤ Malabsorptive: Where segment of intestine is bypassed à less absorptive area à Lesser absorption of food à weight loss.</li><li>➤ Malabsorptive:</li><li>➤ Examples: Biliopancreatic diversion/Duodenal switch, Mini-gastric bypass</li><li>➤ Examples:</li><li>➤ Combined: Where both of above effects are applicable.</li><li>➤ Combined: Where both of above effects are applicable.</li><li>➤ Combined:</li><li>➤ Example: Roux-en-Y gastric bypass</li><li>➤ Example:</li><li>➤ Endoscopic bariatric procedures: non-surgical, purely by endoscopic approach</li><li>➤ Endoscopic bariatric procedures: non-surgical, purely by endoscopic approach</li><li>➤ Endoscopic bariatric procedures:</li><li>➤ Example: Gastric balloon, Endoscopic gastroplasty (principally same as restrictive procedures)</li><li>➤ Example:</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1185</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1185</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "According to the principles of bariatric surgery, which of the following is/are considered as reversible bariatric surgery?", "options": [{"label": "A", "text": "Laparoscopic adjustable Gastric Banding", "correct": false}, {"label": "B", "text": "Laparoscopic Roux-en-Y Gastric Bypass", "correct": false}, {"label": "C", "text": "Laparoscopic Sleeve Gastrectomy", "correct": false}, {"label": "D", "text": "Both A and B", "correct": true}], "correct_answer": "D. Both A and B", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/30/picture19_UXQeT7e.jpg"], "explanation": "<p><strong>Ans. D) Both A and B</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option C. Laparoscopic sleeve gastrectomy involves removing a portion of the stomach to create a smaller, sleeve-shaped stomach . This procedure is not considered reversible because the removed portion of the stomach cannot be replaced.</li><li>• Option C.</li><li>• removing</li><li>• portion</li><li>• stomach</li><li>• create</li><li>• smaller, sleeve-shaped stomach</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Laparoscopic adjustable gastric banding and RYGB considered a reversible bariatric surgery because the band can be removed or adjusted postoperatively , while the Roux-en-Y configuration can be reversed , unlike other forms of bariatric surgery that permanently alter the stomach or digestive tract .</li><li>➤ Laparoscopic adjustable gastric banding</li><li>➤ RYGB</li><li>➤ reversible bariatric surgery</li><li>➤ removed</li><li>➤ adjusted postoperatively</li><li>➤ Roux-en-Y configuration</li><li>➤ reversed</li><li>➤ permanently alter</li><li>➤ stomach</li><li>➤ digestive tract</li><li>➤ Complications of LAGB include:</li><li>➤ Complications of LAGB include:</li><li>➤ Prolapse / Slippage (most common) Band erosion of the stomach wall and rupture Increased risk of DVT and pulmonary embolism (highest risk within 1 month of surgery), managed with early ambulation, pressure stockings and LMWH.</li><li>➤ Prolapse / Slippage (most common)</li><li>➤ (most common)</li><li>➤ Band erosion of the stomach wall and rupture</li><li>➤ Increased risk of DVT and pulmonary embolism (highest risk within 1 month of surgery), managed with early ambulation, pressure stockings and LMWH.</li><li>➤ Increased risk of DVT and pulmonary embolism</li><li>➤ Ref : Bailey and Love, 28 th Ed Pg 1187</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed Pg 1187</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A morbidly obese patient fitting the NICE criteria arrives at your OPD to evaluate the surgical options for her weight reduction. Which is the most commonly done surgical procedure in bariatric today?", "options": [{"label": "A", "text": "Sleeve Gastrectomy", "correct": true}, {"label": "B", "text": "Gastric Banding", "correct": false}, {"label": "C", "text": "Roux en Y Gastric Bypass", "correct": false}, {"label": "D", "text": "Mini-Gastric Bypass", "correct": false}], "correct_answer": "A. Sleeve Gastrectomy", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/30/picture20_PT0Ffua.jpg"], "explanation": "<p><strong>Ans. A) Sleeve Gastrectomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B . Gastric banding was once a popular bariatric surgery , but its frequency has decreased due to the higher prevalence and success rates of other procedures like the sleeve gastrectomy.</li><li>• Option B</li><li>• popular bariatric surgery</li><li>• frequency has decreased</li><li>• higher prevalence</li><li>• success rates</li><li>• Option C . Roux en y gastric bypass is a procedure that involves creating a small pouch from the stomach and connecting it directly to the small intestine . Although it is a common and effective procedure , it is more complex than sleeve gastrectomy and carries a higher risk of complications like internal hernias.</li><li>• Option C</li><li>• creating a small pouch</li><li>• stomach</li><li>• connecting</li><li>• directly</li><li>• small intestine</li><li>• common</li><li>• effective procedure</li><li>• more complex</li><li>• sleeve gastrectomy</li><li>• higher risk</li><li>• complications</li><li>• Option D . Mini-gastric bypass is a variation of the traditional gastric bypass but has not surpassed the sleeve gastrectomy in frequency of performance.</li><li>• Option D</li><li>• traditional gastric bypass</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Sleeve gastrectomy is the most commonly done surgical procedure in bariatrics today due to its simplicity relative to other options and its effectiveness in weight loss .</li><li>➤ Sleeve gastrectomy</li><li>➤ most commonly done surgical procedure</li><li>➤ simplicity</li><li>➤ effectiveness</li><li>➤ weight loss</li><li>➤ Sleeve gastrectomy is a type of restrictive surgery which works on the following principle:</li><li>➤ restrictive surgery</li><li>➤ Where stomach is reduced in size (by creating a vertical sleeve, resecting much of the greater curvature) → reduction in meal size → lower calorie intake → Weight loss. It is the most common surgery done today , since it is less challenging and there is reduction in number of internal hernias.</li><li>➤ most common surgery done today</li><li>➤ Complications of sleeve gastrectomy:</li><li>➤ Complications of sleeve gastrectomy:</li><li>➤ Bleed from staple line Leakage from staple line at angle of His ( upper end ) GERD in the long term</li><li>➤ Bleed from staple line</li><li>➤ Bleed</li><li>➤ staple line</li><li>➤ Leakage from staple line at angle of His ( upper end )</li><li>➤ Leakage</li><li>➤ staple line</li><li>➤ angle of His</li><li>➤ upper end</li><li>➤ GERD in the long term</li><li>➤ GERD</li><li>➤ long term</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1186</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1186</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45 years old lady underwent Roux-en-Y gastric bypass 2 years ago. She comes to the emergency with sudden onset abdominal pain and vomiting. She is afebrile. Abdomen exam shows vague diffuse tenderness. An urgent CECT abdomen is done, which shows dilated small bowel loops. Which of these is a dangerous late complication in this case?", "options": [{"label": "A", "text": "Narrowing of Gastro-Jejunostomy", "correct": false}, {"label": "B", "text": "Internal Hernia", "correct": true}, {"label": "C", "text": "Leak from Staple Line", "correct": false}, {"label": "D", "text": "Pulmonary Embolism", "correct": false}], "correct_answer": "B. Internal Hernia", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Internal Hernia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A . Narrowing of gastro-jejunostomy can cause obstruction and vomiting but would typically not lead to diffuse abdominal tenderness and is more of an early complication post-surgery.</li><li>• Option A</li><li>• obstruction</li><li>• vomiting</li><li>• Option C. A leak from the staple line is generally an early postoperative complication and would typically present with signs of infection such as fever , which is not mentioned in this scenario.</li><li>• Option C.</li><li>• early postoperative complication</li><li>• present with signs of infection</li><li>• fever</li><li>• Option D. Pulmonary embolism could cause sudden onset symptoms but would not explain the finding of dilated small bowel loops on the CECT abdomen.</li><li>• Option D.</li><li>• sudden onset symptoms</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ An internal hernia is a dangerous late complication after Roux-en-Y gastric bypass that can present with symptoms of bowel obstruction and requires high priority for laparoscopic investigation , even in the face of normal imaging studies .</li><li>➤ dangerous late complication</li><li>➤ gastric bypass</li><li>➤ bowel obstruction</li><li>➤ requires high priority</li><li>➤ laparoscopic investigation</li><li>➤ face</li><li>➤ normal imaging studies</li><li>➤ Internal hernias develop as weight is lost and hernia spaces open up after gastric bypass . CT scanning has a high rate of false negatives for internal hernia , so anyone presenting with severe , cramping abdominal pain 2–3 years after surgery needs to be high priority for investigation by laparoscopy . Closure of the internal hernia spaces is now standard of care in Roux-en-Y gastric bypass.</li><li>➤ Internal hernias develop as weight is lost and hernia spaces open up after gastric bypass .</li><li>➤ weight is lost</li><li>➤ hernia spaces</li><li>➤ gastric bypass</li><li>➤ CT scanning has a high rate of false negatives for internal hernia , so anyone presenting with severe , cramping abdominal pain 2–3 years after surgery needs to be high priority for investigation by laparoscopy .</li><li>➤ high rate of false negatives</li><li>➤ internal hernia</li><li>➤ severe</li><li>➤ cramping abdominal pain 2–3 years</li><li>➤ investigation by laparoscopy</li><li>➤ Closure of the internal hernia spaces is now standard of care in Roux-en-Y gastric bypass.</li><li>➤ Closure</li><li>➤ internal hernia spaces</li><li>➤ care</li><li>➤ Complications of Bariatric Surgery:</li><li>➤ Complications of Bariatric Surgery:</li><li>➤ Related to Surgery : Postoperative bleed, post-operative staple line leak, internal hernia, band erosion. Related to Obesity : Deep vein thrombosis, pulmonary embolism (most common cause of death), respiratory failure. Related to Reduced Food Intake/Malabsorption : Hypo-proteinemia, anemia, vitamin deficiencies (Vit B12/Vit D etc.).</li><li>➤ Related to Surgery : Postoperative bleed, post-operative staple line leak, internal hernia, band erosion.</li><li>➤ Related to Surgery</li><li>➤ Related to Obesity : Deep vein thrombosis, pulmonary embolism (most common cause of death), respiratory failure.</li><li>➤ Related to Obesity</li><li>➤ Related to Reduced Food Intake/Malabsorption : Hypo-proteinemia, anemia, vitamin deficiencies (Vit B12/Vit D etc.).</li><li>➤ Related to Reduced Food Intake/Malabsorption</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1188-89</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1188-89</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these bariatric procedures leads to maximum weight loss and nutritional deficiencies?", "options": [{"label": "A", "text": "Gastric Band", "correct": false}, {"label": "B", "text": "Roux en Y Gastric Bypass", "correct": false}, {"label": "C", "text": "Sleeve Gastrectomy", "correct": false}, {"label": "D", "text": "Duodenal Switch", "correct": true}], "correct_answer": "D. Duodenal Switch", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/30/screenshot-2023-12-30-183138.jpg"], "explanation": "<p><strong>Ans. D) Duodenal Switch</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Gastric band is a restrictive bariatric procedure that reduces food intake by creating a small pouch at the top of the stomach . It generally results in moderate weight loss and has a lower risk of nutritional deficiencies compared to more invasive surgeries .</li><li>• Option A.</li><li>• restrictive bariatric procedure</li><li>• reduces food intake</li><li>• small pouch</li><li>• top</li><li>• stomach</li><li>• moderate weight loss</li><li>• lower risk</li><li>• nutritional deficiencies</li><li>• more invasive surgeries</li><li>• Option B . Roux en Y gastric bypass is a combination of restrictive and malabsorptive procedures and can lead to significant weight loss and nutritional deficiencies , but not typically to the extent seen with more malabsorptive procedures.</li><li>• Option B</li><li>• combination</li><li>• restrictive</li><li>• malabsorptive procedures</li><li>• significant weight loss</li><li>• nutritional deficiencies</li><li>• Option C. Sleeve gastrectomy is mainly a restrictive procedure that removes a portion of the stomach. It can lead to substantial weight loss , but because there is no bypass of the intestines, it generally causes fewer nutritional deficiencies than malabsorptive procedures.</li><li>• Option C.</li><li>• restrictive procedure</li><li>• removes</li><li>• portion</li><li>• substantial weight loss</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The duodenal switch bariatric procedure leads to the most significant weight loss and the highest risk of nutritional deficiencies due to its extensive malabsorptive component .</li><li>➤ switch bariatric procedure</li><li>➤ most significant weight loss</li><li>➤ highest risk</li><li>➤ nutritional deficiencies</li><li>➤ extensive malabsorptive component</li><li>➤ Note: % EWL= Excess Weight Loss</li><li>➤ Note:</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1185.</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1185.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the mismatch in the bariatric procedures and associated complications:", "options": [{"label": "A", "text": "Sleeve Gastrectomy- GERD is a long term Complication", "correct": false}, {"label": "B", "text": "Sleeve Gastrectomy- Leak from Upper Staple Line is the “Achilles Heel”", "correct": false}, {"label": "C", "text": "Internal Hernia- Seen after Roux en Y gastric bypass", "correct": false}, {"label": "D", "text": "Gastric Band- Protein Energy Malnutrition", "correct": true}], "correct_answer": "D. Gastric Band- Protein Energy Malnutrition", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Gastric band- Protein Energy Malnutrition</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. This statement is accurate . Sleeve gastrectomy may lead to the development or exacerbation of gastroesophageal reflux disease (GERD) as a long-term complication .</li><li>• Option A.</li><li>• accurate</li><li>• may lead</li><li>• development</li><li>• exacerbation</li><li>• gastroesophageal reflux disease (GERD)</li><li>• long-term complication</li><li>• Option B. This statement is accurate . One of the potential complications of sleeve gastrectomy is a leak from the upper staple line . The staple line is a vulnerable area where leakage can occur . Patients are typically in hospital for months and need multiple reinterventions , including any of: endoscopic interventions ( stenting, endoscopic vacuum therapy ), making a controlled fistula , conversion to gastric bypass and fistula enterostomy .</li><li>• Option B.</li><li>• accurate</li><li>• leak</li><li>• upper staple line</li><li>• vulnerable area</li><li>• leakage can occur</li><li>• hospital for months</li><li>• multiple reinterventions</li><li>• endoscopic interventions</li><li>• stenting, endoscopic vacuum therapy</li><li>• controlled fistula</li><li>• gastric bypass</li><li>• fistula enterostomy</li><li>• Option C. This statement is accurate . Internal hernias are a known complication after Roux-en-Y gastric bypass, through the Peterson space .</li><li>• Option C.</li><li>• accurate</li><li>• Peterson space</li><li>• Ref : Bailey 28 th Ed. Pg 1188.</li><li>• Ref</li><li>• : Bailey 28 th Ed. Pg 1188.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In Coronary artery bypass graft (CABG) surgery, conduit of choice for grafting the Left anterior descending coronary artery occlusion is:", "options": [{"label": "A", "text": "Left Internal Mammary Artery", "correct": true}, {"label": "B", "text": "Great Saphenous Vein", "correct": false}, {"label": "C", "text": "Right Internal Mammary Artery", "correct": false}, {"label": "D", "text": "Left Radial Artery Graft", "correct": false}], "correct_answer": "A. Left Internal Mammary Artery", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B . The Great saphenous vein, while commonly used in CABG for its ease of harvest and length , is more prone to atherosclerosis and has a lower long-term patency rate compared to arterial grafts .</li><li>• Option B</li><li>• ease</li><li>• harvest</li><li>• length</li><li>• more prone</li><li>• atherosclerosis</li><li>• lower long-term patency rate</li><li>• arterial grafts</li><li>• Option C . The Right internal mammary artery is also a good option for grafting and can be used for the LAD , but the LIMA is preferred because of its closer proximity and direct course to the LAD .</li><li>• Option C</li><li>• good option</li><li>• grafting</li><li>• LAD</li><li>• LIMA</li><li>• closer proximity</li><li>• direct course</li><li>• LAD</li><li>• Option D. The Left radial artery graft can be used for coronary bypass ; however, it is generally reserved for situations where the internal mammary arteries are not usable or in multiple arterial grafting strategies.</li><li>• Option D.</li><li>• coronary bypass</li><li>• internal mammary arteries</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ The left internal mammary artery (LIMA) is the conduit of choice for grafting the left anterior descending (LAD) coronary artery occlusion in CABG surgery due to its excellent long-term patency and proximity to the LAD.</li><li>➤ excellent long-term patency</li><li>➤ proximity to the LAD.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 950</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 950</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is not an indication of Cardiopulmonary bypass?", "options": [{"label": "A", "text": "Lung Transplant", "correct": false}, {"label": "B", "text": "Vascular Tumour Excision", "correct": false}, {"label": "C", "text": "CABG (Coronary Artery Bypass Graft)", "correct": false}, {"label": "D", "text": "IVC filter insertion in Pulmonary Thromboembolism", "correct": true}], "correct_answer": "D. IVC filter insertion in Pulmonary Thromboembolism", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) IVC filter insertion in Pulmonary Thromboembolism</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A . Lung transplant surgery is a complex procedure that often requires cardiopulmonary bypass to maintain circulation and oxygenation while the diseased lungs are replaced .</li><li>• Option A</li><li>• complex procedure</li><li>• cardiopulmonary bypass</li><li>• circulation</li><li>• oxygenation</li><li>• diseased lungs are replaced</li><li>• Option B . Vascular tumor excision can necessitate the use of cardiopulmonary bypass , especially if the tumor is within or adjacent to the heart or great vessels , to maintain blood flow and organ perfusion during the surgery .</li><li>• Option B</li><li>• cardiopulmonary bypass</li><li>• tumor</li><li>• within</li><li>• adjacent</li><li>• heart</li><li>• great vessels</li><li>• blood flow</li><li>• organ perfusion</li><li>• surgery</li><li>• Option C. Coronary artery bypass grafting (CABG) is a common indication for cardiopulmonary bypass as it allows the heart to be still while bypasses are created to route blood around clogged arteries .</li><li>• Option C.</li><li>• cardiopulmonary bypass</li><li>• heart</li><li>• still</li><li>• bypasses</li><li>• route blood</li><li>• clogged arteries</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The insertion of an inferior vena cava (IVC) filter in the case of pulmonary thromboembolism is not an indication for cardiopulmonary bypass, as it is a minimally invasive procedure that does not necessitate the cessation of heart and lung function.</li><li>➤ minimally invasive procedure</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 945</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 945</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these are mechanical support devices for low cardiac output?", "options": [{"label": "A", "text": "ECMO (Extra-Corporeal Membrane Oxygenation)", "correct": false}, {"label": "B", "text": "IABP (Intra-Aortic Balloon Pump)", "correct": false}, {"label": "C", "text": "VAD (Ventricular Assist Devices)", "correct": false}, {"label": "D", "text": "All of the above", "correct": true}], "correct_answer": "D. All of the above", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/19/picture15_Liu8coh.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/19/picture16.jpg"], "explanation": "<p><strong>Ans. D) All of the above</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. ECMO, or Extracorporeal Membrane Oxygenation, is a device that provides both cardiac and respiratory support to patients whose heart and lungs are so severely diseased or damaged that they can no longer serve their function adequately. It does the function of oxygenation of blood .</li><li>• Option A.</li><li>• both cardiac</li><li>• respiratory support</li><li>• heart</li><li>• lungs</li><li>• severely diseased</li><li>• damaged</li><li>• oxygenation of blood</li><li>• Option B . The IABP, or Intra-aortic Balloon Pump, is a mechanical device that increases myocardial oxygen perfusion and simultaneously increases cardiac output . It is inserted into the aorta and helps the heart by reducing afterload and increasing blood flow to the coronary arteries .</li><li>• Option B</li><li>• mechanical device</li><li>• increases myocardial oxygen perfusion</li><li>• increases cardiac output</li><li>• inserted</li><li>• aorta</li><li>• heart</li><li>• reducing afterload</li><li>• increasing blood flow</li><li>• coronary arteries</li><li>• Option C. VADs, or Ventricular Assist Devices, are mechanical pumps that are used to support heart function and blood flow in individuals with refractory heart failure .</li><li>• Option C.</li><li>• mechanical pumps</li><li>• support heart function</li><li>• blood flow</li><li>• refractory heart failure</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ In the event of persistent low cardiac output that does not respond to inotropic support, mechanical support devices such as ECMO, IABP, and VADs may be employed to aid heart function .</li><li>➤ persistent low cardiac output</li><li>➤ employed</li><li>➤ aid heart function</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 952</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 952</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 70-year-old male with h/o atherosclerosis comes to the hospital with sudden onset chest pain that mimics angina. The pain radiates to interscapular region. A CT thoracic angiography shows an aortic dissection involving the descending aorta alone, classified as Stanford class B. What would be the preferred treatment for the same?", "options": [{"label": "A", "text": "Surgical Repair", "correct": false}, {"label": "B", "text": "Endovascular Stenting", "correct": true}, {"label": "C", "text": "Conservative Management", "correct": false}, {"label": "D", "text": "Both A and B", "correct": false}], "correct_answer": "B. Endovascular Stenting", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Endovascular Stenting</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Surgical repair is typically indicated for aortic dissections involving the ascending aorta ( Stanford Class A ) due to the higher risk of lethal complications such as rupture into the pericardial space , leading to cardiac tamponade .</li><li>• Option A.</li><li>• aortic dissections</li><li>• ascending aorta</li><li>• Stanford Class A</li><li>• higher risk</li><li>• lethal complications</li><li>• rupture</li><li>• pericardial space</li><li>• cardiac tamponade</li><li>• Option C. Conservative management, including blood pressure control , may be appropriate for cases of aortic dissection where surgical or endovascular intervention is not immediately indicated or if the patient has comorbid conditions that increase the risk of surgical procedures .</li><li>• Option C.</li><li>• blood pressure control</li><li>• aortic dissection</li><li>• surgical</li><li>• endovascular intervention</li><li>• increase the risk of surgical procedures</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The recommended treatment for a Stanford Class B aortic dissection, which does not involve the ascending aorta, is endovascular stenting , following initial blood pressure management .</li><li>➤ endovascular stenting</li><li>➤ initial blood pressure management</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 970</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 970</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In TNM staging of Lung cancer, Stage T1c implies:", "options": [{"label": "A", "text": "Tumor size 2-3 cm", "correct": true}, {"label": "B", "text": "Tumor size 3-4 cm", "correct": false}, {"label": "C", "text": "Tumor size 4-5 cm", "correct": false}, {"label": "D", "text": "Tumor size 5-7 cm", "correct": false}], "correct_answer": "A. Tumor size 2-3 cm", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/09/25/staging_page_1.jpg"], "explanation": "<p><strong>Ans. A) Tumor size 2-3 cm</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ TNM staging lung cancer</li><li>➤ TNM staging lung cancer</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 985-991</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 985-991</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Most common Posterior Mediastinal Mass is:", "options": [{"label": "A", "text": "Thymoma", "correct": false}, {"label": "B", "text": "Neurogenic Tumors", "correct": true}, {"label": "C", "text": "Paravertebral Abscess", "correct": false}, {"label": "D", "text": "Lymphoma", "correct": false}], "correct_answer": "B. Neurogenic Tumors", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/19/screenshot-2023-12-19-174047.jpg"], "explanation": "<p><strong>Ans. B) Neurogenic Tumors</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Thymoma is a tumor originating from the thymic tissue and is most commonly located in the anterior mediastinum , not the posterior mediastinum.</li><li>• Option A.</li><li>• tumor</li><li>• thymic tissue</li><li>• anterior mediastinum</li><li>• Option C . Paravertebral abscesses are collections of pus near the vertebral column . They can present as a mass in the posterior mediastinum but are not the most common.</li><li>• Option C</li><li>• collections of pus</li><li>• vertebral column</li><li>• mass</li><li>• posterior mediastinum</li><li>• Option D . Lymphomas can involve the mediastinum , but they are not the most common posterior mediastinal mass; they more frequently involve the anterior or superior mediastinum .</li><li>• Option D</li><li>• mediastinum</li><li>• anterior</li><li>• superior mediastinum</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most common posterior mediastinal mass is a neurogenic tumor .</li><li>➤ posterior mediastinal mass</li><li>➤ neurogenic tumor</li><li>➤ Types of mediastinal masses</li><li>➤ Types of mediastinal masses</li><li>➤ MC Anterior Mediastinal Mass: Thymoma MC Post Mediastinal Mass: Neuromas/Neurogenic Tumors</li><li>➤ MC Anterior Mediastinal Mass: Thymoma</li><li>➤ Thymoma</li><li>➤ MC Post Mediastinal Mass: Neuromas/Neurogenic Tumors</li><li>➤ Neuromas/Neurogenic Tumors</li><li>➤ Ref: Bailey and Love’s short practice of surgery 28th edition pg 992-993</li><li>➤ Ref: Bailey and Love’s short practice of surgery 28th edition pg 992-993</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Masaoka staging is used to classify:", "options": [{"label": "A", "text": "Parathyroid Adenoma", "correct": false}, {"label": "B", "text": "Neuroma", "correct": false}, {"label": "C", "text": "Thymoma", "correct": true}, {"label": "D", "text": "Bronchogenic Cyst", "correct": false}], "correct_answer": "C. Thymoma", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Thymoma</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Masaoka staging system is used to classify thymoma , assessing the degree of tumor invasion to guide treatment, which commonly includes thymectomy .</li><li>➤ Masaoka staging system</li><li>➤ classify thymoma</li><li>➤ degree of tumor invasion</li><li>➤ thymectomy</li><li>➤ This is the most common anterior mediastinal tumour , accounting for 25% of the total , and is derived from the thymus gland . Thymomas vary in behaviour from benign to aggressively invasive, as classified in the Masoaka classification system used to stage thymomas and more recently the TNM classification. They are often related to myasthenia gravis , a neuromuscular condition that can have a high associated incidence of thymomas , and interestingly may respond to excision of the thymus gland even when the gland has no associated thymoma present. The only reliable indicator of malignancy is capsular invasion . Diagnosis and treatment are best achieved by complete thymectomy , which for large tumours (&gt;5 cm) Treatment - Thymectomy : Open surgery / video assisted thoracoscopic surgery ( VATS )</li><li>➤ This is the most common anterior mediastinal tumour , accounting for 25% of the total , and is derived from the thymus gland .</li><li>➤ anterior mediastinal tumour</li><li>➤ 25%</li><li>➤ total</li><li>➤ thymus gland</li><li>➤ Thymomas vary in behaviour from benign to aggressively invasive, as classified in the Masoaka classification system used to stage thymomas and more recently the TNM classification.</li><li>➤ vary</li><li>➤ behaviour from benign</li><li>➤ aggressively invasive,</li><li>➤ They are often related to myasthenia gravis , a neuromuscular condition that can have a high associated incidence of thymomas , and interestingly may respond to excision of the thymus gland even when the gland has no associated thymoma present.</li><li>➤ myasthenia gravis</li><li>➤ neuromuscular condition</li><li>➤ high associated incidence</li><li>➤ thymomas</li><li>➤ interestingly</li><li>➤ excision</li><li>➤ thymus gland</li><li>➤ The only reliable indicator of malignancy is capsular invasion .</li><li>➤ only reliable indicator</li><li>➤ capsular invasion</li><li>➤ Diagnosis and treatment are best achieved by complete thymectomy , which for large tumours (&gt;5 cm)</li><li>➤ complete thymectomy</li><li>➤ large tumours</li><li>➤ (&gt;5 cm)</li><li>➤ Treatment - Thymectomy : Open surgery / video assisted thoracoscopic surgery ( VATS )</li><li>➤ Thymectomy</li><li>➤ Open surgery</li><li>➤ video assisted thoracoscopic surgery</li><li>➤ VATS</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 992</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 992</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 4-year-old child presents with obstructive hydrocephalus secondary to a suspected brain tumor. What is the first line investigation in this patient?", "options": [{"label": "A", "text": "MRI Brain", "correct": false}, {"label": "B", "text": "CT Brain", "correct": true}, {"label": "C", "text": "CSF Manometry", "correct": false}, {"label": "D", "text": "Lumbar Puncture", "correct": false}], "correct_answer": "B. CT Brain", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) CT Brain</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A . MRI Brain provides detailed images of the brain's anatomy and can be useful in assessing brain tumors . However, it is not typically the first-line investigation due to the time it takes to perform and the need for sedation in young children.</li><li>• Option A</li><li>• brain's anatomy</li><li>• assessing brain tumors</li><li>• Option C . CSF manometry is used to measure the pressure of the cerebrospinal fluid but is not the first-line investigation for a brain tumor or hydrocephalus, and it can be dangerous in the presence of increased intracranial pressure due to mass effect .</li><li>• Option C</li><li>• measure</li><li>• pressure</li><li>• cerebrospinal fluid</li><li>• dangerous</li><li>• presence</li><li>• increased intracranial pressure</li><li>• mass effect</li><li>• Option D. Lumbar puncture is contraindicated as an initial investigation in the presence of raised intracranial pressure due to the risk of brain herniation ; it is performed after imaging has excluded obstructive hydrocephalus .</li><li>• Option D.</li><li>• contraindicated as an initial investigation</li><li>• risk of brain herniation</li><li>• after imaging</li><li>• obstructive hydrocephalus</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The first-line investigation for a child with obstructive hydrocephalus suspected to be secondary to a brain tumor is a CT brain scan to rapidly assess for mass effect and guide further management .</li><li>➤ first-line investigation</li><li>➤ child</li><li>➤ obstructive hydrocephalus</li><li>➤ CT brain scan</li><li>➤ assess for mass effect</li><li>➤ guide further management</li><li>➤ Types of Hydrocephalus</li><li>➤ Types of Hydrocephalus</li><li>➤ 1. Obstructive : masses/ tumours / infection</li><li>➤ Obstructive</li><li>➤ 2. Non obstructive / communicating : defective absorption</li><li>➤ Non obstructive / communicating</li><li>➤ Secondary to meningitis Secondary to sub arachnoid haemorrhage (lining which absorbs CSF is damaged)</li><li>➤ Secondary to meningitis</li><li>➤ Secondary to sub arachnoid haemorrhage (lining which absorbs CSF is damaged)</li><li>➤ 3. Excessive CSF production - very rare</li><li>➤ Excessive CSF production</li><li>➤ First line Investigation - CT BRAIN: dilated ventricles, provides clue to etiology</li><li>➤ Lumbar puncture done after CT scan: done only if it is non- obstructive.</li><li>➤ Lumbar puncture done after CT scan: done only if it is non- obstructive.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 703</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 703</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In a Ventriculoperitoneal Shunt Surgery, the upper end of the shunt is inserted into:", "options": [{"label": "A", "text": "Lateral Ventricles", "correct": true}, {"label": "B", "text": "3 rd Ventricle", "correct": false}, {"label": "C", "text": "4 th Ventricle", "correct": false}, {"label": "D", "text": "Cisterna Magna", "correct": false}], "correct_answer": "A. Lateral Ventricles", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Lateral Ventricles</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B . The 3rd ventricle is not a common site for shunt placement in ventriculoperitoneal shunting. It is, however, the site targeted in endoscopic third ventriculostomy , which is a different procedure.</li><li>• Option B</li><li>• endoscopic third ventriculostomy</li><li>• Option C . The 4th ventricle is also not typically used for the insertion of the upper end of a ventriculoperitoneal shunt. Access to the fourth ventricle is more complex and not necessary for routine CSF shunting.</li><li>• Option C</li><li>• Access</li><li>• more complex</li><li>• Option D. The Cisterna magna is not used for the placement of a ventriculoperitoneal shunt. It is sometimes accessed in the placement of a lumboperitoneal shunt or for certain diagnostic procedures.</li><li>• Option D.</li><li>• accessed</li><li>• placement</li><li>• lumboperitoneal shunt</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In ventriculoperitoneal shunt surgery, the upper end of the shunt is inserted into the lateral ventricles to treat hydrocephalus . The lower end is placed into the intra-peritoneal cavity , and a valve regulates the flow of CSF .</li><li>➤ lateral ventricles</li><li>➤ treat hydrocephalus</li><li>➤ intra-peritoneal cavity</li><li>➤ valve regulates the flow of CSF</li><li>➤ Treatment of hydrocephalus</li><li>➤ External ventricular drain Endoscopic third ventriculostomy Ventriculoperitoneal shunt Upper end is put into lateral ventricles Lower end into Intra peritoneal cavity A shunt valve inserted between the proximal and distal catheters regulates flow through the system by opening at a predetermined pressure; the shunt valve typically incorporates a CSF reservoir, which allows for percutaneous sampling.</li><li>➤ External ventricular drain</li><li>➤ External ventricular drain</li><li>➤ Endoscopic third ventriculostomy</li><li>➤ Endoscopic third ventriculostomy</li><li>➤ Ventriculoperitoneal shunt Upper end is put into lateral ventricles Lower end into Intra peritoneal cavity A shunt valve inserted between the proximal and distal catheters regulates flow through the system by opening at a predetermined pressure; the shunt valve typically incorporates a CSF reservoir, which allows for percutaneous sampling.</li><li>➤ Ventriculoperitoneal shunt</li><li>➤ Upper end is put into lateral ventricles Lower end into Intra peritoneal cavity A shunt valve inserted between the proximal and distal catheters regulates flow through the system by opening at a predetermined pressure; the shunt valve typically incorporates a CSF reservoir, which allows for percutaneous sampling.</li><li>➤ Upper end is put into lateral ventricles</li><li>➤ Lower end into Intra peritoneal cavity</li><li>➤ A shunt valve inserted between the proximal and distal catheters regulates flow through the system by opening at a predetermined pressure; the shunt valve typically incorporates a CSF reservoir, which allows for percutaneous sampling.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 705</li><li>➤ Ref</li><li>➤ :</li><li>➤ Bailey and Love’s short practice of surgery 28 th edition pg 705</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Most common tissue of origin for brain metastases is:", "options": [{"label": "A", "text": "Lung", "correct": true}, {"label": "B", "text": "Liver", "correct": false}, {"label": "C", "text": "Kidney", "correct": false}, {"label": "D", "text": "Breast", "correct": false}], "correct_answer": "A. Lung", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/09/13/whatsapp-image-2023-07-04-at-1256120_page_17_page_18.jpg"], "explanation": "<p><strong>Ans. A) Lung</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 715</li><li>➤ Ref :</li><li>➤ Bailey and Love’s short practice of surgery 28 th edition pg 715</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old male presents with personality change, gait disturbance and urinary incontinence since 2 months. A CT Brain is likely to show a mass in which lobe?", "options": [{"label": "A", "text": "Temporal", "correct": false}, {"label": "B", "text": "Parietal", "correct": false}, {"label": "C", "text": "Occipital", "correct": false}, {"label": "D", "text": "Frontal", "correct": true}], "correct_answer": "D. Frontal", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/09/13/whatsapp-image-2023-07-04-at-1256120_page_17_page_15.jpg"], "explanation": "<p><strong>Ans. D) Frontal</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. The Temporal lobe is primarily involved with processing auditory information and memory . Lesions here might lead to problems with memory , understanding language , or disturbances in hearing .</li><li>• Option A.</li><li>• processing auditory information</li><li>• memory</li><li>• problems with memory</li><li>• understanding language</li><li>• disturbances in hearing</li><li>• Option B . The Parietal lobe integrates sensory information from various modalities, including spatial sense and navigation (proprioception) , the main sensory receptive area for the sense of touch . Disturbances here typically affect spatial awareness and proprioception .</li><li>• Option B</li><li>• sensory information</li><li>• modalities,</li><li>• spatial sense</li><li>• navigation (proprioception)</li><li>• sense of touch</li><li>• affect spatial awareness</li><li>• proprioception</li><li>• Option C . The Occipital lobe is the visual processing center of the brain . Lesions in the occipital lobe can lead to visual deficits like blindness or visual field cuts .</li><li>• Option C</li><li>• visual processing center</li><li>• brain</li><li>• occipital lobe</li><li>• visual deficits</li><li>• blindness</li><li>• visual field cuts</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ A mass in the frontal lobe of the brain can present with personality changes , gait disturbances , and urinary incontinence , correlating with the functions mediated by this area of the brain .</li><li>➤ frontal lobe</li><li>➤ brain</li><li>➤ personality changes</li><li>➤ gait disturbances</li><li>➤ urinary incontinence</li><li>➤ area</li><li>➤ brain</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 714</li><li>➤ Ref</li><li>➤ :</li><li>➤ Bailey and Love’s short practice of surgery 28 th edition pg 714</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 55-year-old man presents to the emergency room with severe chest pain and difficulty swallowing. A CT scan with water soluble contrast reveals an esophageal perforation. What is the most common etiology of esophageal perforation?", "options": [{"label": "A", "text": "Spontaneous", "correct": false}, {"label": "B", "text": "Blunt trauma to chest", "correct": false}, {"label": "C", "text": "Instrumental", "correct": true}, {"label": "D", "text": "Penetrating trauma to chest", "correct": false}], "correct_answer": "C. Instrumental", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Instrumental</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Spontaneous. Spontaneous perforation of the esophagus , also known as Boerhaave syndrome , is a serious condition but not the most common cause . It occurs due to vomiting against a closed glottis , which leads to a sudden increase in esophageal pressure and typically results in perforation of the lower esophagus.</li><li>• Option A: Spontaneous.</li><li>• Spontaneous perforation</li><li>• esophagus</li><li>• Boerhaave syndrome</li><li>• serious condition but not the most common cause</li><li>• due to vomiting against a closed glottis</li><li>• increase in esophageal pressure</li><li>• perforation of the lower esophagus.</li><li>• Option B: Blunt trauma to the chest. Blunt trauma can cause esophageal perforation ; however, it is less common than iatrogenic causes related to medical procedures.</li><li>• Option B: Blunt trauma to the chest.</li><li>• cause esophageal perforation</li><li>• less common than iatrogenic</li><li>• Option D: Penetrating trauma to chest. Penetrating trauma is another possible cause of esophageal injury , but again, it is not as common as iatrogenic causes.</li><li>• Option D: Penetrating trauma to chest.</li><li>• another possible cause of esophageal injury</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most common cause of esophageal perforation is iatrogenic injury during instrumental procedures such as upper GI endoscopy, dilatation, and stenting .</li><li>➤ most common cause of esophageal perforation</li><li>➤ iatrogenic injury</li><li>➤ instrumental procedures</li><li>➤ upper GI endoscopy, dilatation, and stenting</li><li>➤ Iatrogenic perforation secondary to endoscopic procedures such as dilatation of strictures or achalasia is the most common cause. Esophageal perforation can occur due to instrumental procedures such as upper GI endoscopy , dilatation, and stenting. Spontaneous esophageal perforation , also known as Boerhaave syndrome , can occur when vomiting against a closed glottis , resulting in a massive increase in esophageal pressure and typically perforating the lower esophagus over the left pleura. CT with water-soluble contrast is the ideal imaging modality to diagnose esophageal perforation. Treatment options for esophageal perforation include conservative management for small perforations and surgery for septic load (Boerhaave syndrome), unstable mediastinitis, or intra-abdominal esophageal perforation.</li><li>➤ Iatrogenic perforation secondary to endoscopic procedures such as dilatation of strictures or achalasia is the most common cause.</li><li>➤ Iatrogenic perforation</li><li>➤ most common cause.</li><li>➤ Esophageal perforation can occur due to instrumental procedures such as upper GI endoscopy , dilatation, and stenting.</li><li>➤ Esophageal perforation</li><li>➤ instrumental procedures such as upper GI endoscopy</li><li>➤ Spontaneous esophageal perforation , also known as Boerhaave syndrome , can occur when vomiting against a closed glottis , resulting in a massive increase in esophageal pressure and typically perforating the lower esophagus over the left pleura.</li><li>➤ Spontaneous esophageal perforation</li><li>➤ Boerhaave syndrome</li><li>➤ vomiting against a closed glottis</li><li>➤ massive increase in esophageal pressure</li><li>➤ CT with water-soluble contrast is the ideal imaging modality to diagnose esophageal perforation.</li><li>➤ CT with water-soluble contrast</li><li>➤ ideal imaging modality</li><li>➤ Treatment options for esophageal perforation include conservative management for small perforations and surgery for septic load (Boerhaave syndrome), unstable mediastinitis, or intra-abdominal esophageal perforation.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1127</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1127</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which type of esophageal perforation requires urgent surgical exploration?", "options": [{"label": "A", "text": "Cervical", "correct": false}, {"label": "B", "text": "Endoscope induced", "correct": false}, {"label": "C", "text": "Spontaneous", "correct": true}, {"label": "D", "text": "Malignant perforation", "correct": false}], "correct_answer": "C. Spontaneous", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Spontaneous</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Cervical: Esophageal perforation in the cervical region is rare but can occur due to trauma or surgical procedures . Depending on the size and severity of the perforation, it may require urgent surgical exploration.</li><li>• Option A. Cervical:</li><li>• Esophageal perforation</li><li>• cervical region is rare</li><li>• due to trauma or surgical procedures</li><li>• Option B. Scope induced: Esophageal perforation induced by an upper GI endoscopy, dilatation, or stenting can range from small mucosal tears to full-thickness perforations. The size and extent of the perforation will determine the treatment approach. Small perforations may be managed conservatively, while larger perforations may require surgical exploration.</li><li>• Option B. Scope induced:</li><li>• induced by an upper GI endoscopy, dilatation, or stenting</li><li>• Option D. Oesophageal cancer can perforate , and the prognosis is usually poor since it reflects the underlying advanced disease.</li><li>• Option D. Oesophageal cancer</li><li>• perforate</li><li>• prognosis is usually poor</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Urgent surgical exploration is most commonly required for spontaneous esophageal perforations , also known as Boerhaave syndrome , due to the typically large rupture and associated high septic load . It can occur when vomiting against a closed glottis, resulting in a massive increase in esophageal pressure and typically perforating the lower esophagus over the left pleura.</li><li>➤ Urgent surgical exploration</li><li>➤ commonly required for spontaneous esophageal perforations</li><li>➤ Boerhaave syndrome</li><li>➤ large rupture and associated high septic load</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1128.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1128.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which type of caustic injury to esophagus causes deeper tissue damage?", "options": [{"label": "A", "text": "Acid poisons", "correct": false}, {"label": "B", "text": "Alkali poisons", "correct": true}, {"label": "C", "text": "Both acid and alkali poisons cause the same extent of damage", "correct": false}, {"label": "D", "text": "Caustic injury does not cause tissue damage", "correct": false}], "correct_answer": "B. Alkali poisons", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Alkali poisons</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Acid poisons cause coagulative necrosis , which results in superficial tissue damage . The extent of trauma is generally less than that caused by alkali poisons.</li><li>• Option A.</li><li>• Acid poisons cause coagulative necrosis</li><li>• superficial tissue damage</li><li>• Option C. Acid and alkali poisons cause different types of tissue damage, with alkali poisons causing deeper damage than acid poisons .</li><li>• Option C.</li><li>• alkali poisons causing deeper damage than acid poisons</li><li>• Option D. Caustic injury always causes tissue damage and can lead to scarring and strictures in the esophagus, stomach, and duodenum. It is a premalignant condition for esophageal carcinoma.</li><li>• Option D.</li><li>• Caustic injury</li><li>• scarring and strictures</li><li>• premalignant condition</li><li>• Therefore, the correct answer is B) Alkali poisons cause deeper tissue damage than acid poisons.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Alkali poisons cause deeper tissue damage to the esophagus compared to acid poisons due to their mechanism of causing liquefactive necrosis , which allows for deeper penetration and more extensive injury .</li><li>➤ Alkali poisons</li><li>➤ deeper tissue damage to the esophagus</li><li>➤ acid poisons due to their mechanism of causing liquefactive necrosis</li><li>➤ deeper penetration and more extensive injury</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1129-30</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1129-30</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 5-year-old child accidentally swallowed a foreign object while playing. What is the most dangerous foreign object that a child can swallow?", "options": [{"label": "A", "text": "Food bolus", "correct": false}, {"label": "B", "text": "Fish Bone", "correct": false}, {"label": "C", "text": "Battery", "correct": true}, {"label": "D", "text": "Coin", "correct": false}], "correct_answer": "C. Battery", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Battery</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Food bolus . A food bolus can cause obstruction but is typically not as dangerous as other objects because it often softens and passes through the gastrointestinal tract or can be removed endoscopically without causing significant damage.</li><li>• Option A: Food bolus</li><li>• obstruction</li><li>• not as dangerous as other objects because it often softens and passes through the gastrointestinal tract</li><li>• Option B: Fish Bone . A fish bone can be sharp and potentially puncture the esophagus or other parts of the gastrointestinal tract . However, it is generally less harmful compared to corrosive or electrically charged objects because it does not cause tissue necrosis or systemic toxicity.</li><li>• Option B: Fish Bone</li><li>• sharp and potentially puncture the esophagus</li><li>• gastrointestinal tract</li><li>• less harmful compared to corrosive or electrically charged objects</li><li>• does not cause tissue necrosis</li><li>• Option D: Coin. A coin can become lodged in the esophagus , particularly at one of the natural constrictions , but it generally does not cause the same degree of tissue damage as a battery . The coin can often be retrieved endoscopically without significant complication.</li><li>• Option D: Coin.</li><li>• lodged in the esophagus</li><li>• one of the natural constrictions</li><li>• does not cause the same degree of tissue damage as a battery</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most dangerous foreign object that a child can swallow is a battery due to the risk of electrical discharge , leakage of caustic substances, and the potential for rapid tissue damage and necrosis.</li><li>➤ most dangerous foreign object</li><li>➤ child can swallow is a battery</li><li>➤ risk of electrical discharge</li><li>➤ Swallowing a foreign object can be a serious medical emergency, especially in children. The most common foreign objects that are swallowed are food boluses and bones . However, the most dangerous foreign object that a child can swallow is a battery. The esophagus has several constrictions where foreign objects can become lodged. The three most common locations for foreign body impaction are at the cricopharynx (15cm from the incisors), at the left bronchus crossing the esophagus (25cm from the incisors), and at the diaphragmatic pleura (40cm from the incisors). The first step in managing a swallowed foreign body is to obtain a chest X-ray to determine the location of the object. If the object is in the esophagus or stomach, endoscopic retrieval may be possible . However, if the object is a battery, it must be removed as an emergency via endoscopy or colonoscopy , depending on the location of the foreign body.</li><li>➤ Swallowing a foreign object can be a serious medical emergency, especially in children. The most common foreign objects that are swallowed are food boluses and bones . However, the most dangerous foreign object that a child can swallow is a battery.</li><li>➤ The most common foreign objects that are swallowed are food boluses and bones</li><li>➤ The esophagus has several constrictions where foreign objects can become lodged. The three most common locations for foreign body impaction are at the cricopharynx (15cm from the incisors), at the left bronchus crossing the esophagus (25cm from the incisors), and at the diaphragmatic pleura (40cm from the incisors).</li><li>➤ cricopharynx</li><li>➤ left bronchus crossing the esophagus</li><li>➤ at the diaphragmatic pleura</li><li>➤ The first step in managing a swallowed foreign body is to obtain a chest X-ray to determine the location of the object. If the object is in the esophagus or stomach, endoscopic retrieval may be possible . However, if the object is a battery, it must be removed as an emergency via endoscopy or colonoscopy , depending on the location of the foreign body.</li><li>➤ If the object is in the esophagus or stomach, endoscopic retrieval may be possible</li><li>➤ if the object is a battery, it must be removed as an emergency via endoscopy or colonoscopy</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1132</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1132</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 30-year-old female presents with colicky abdominal pain and bilious vomiting. She reports weight loss following a keto-diet in the past few months. On investigation, the small bowel appears normal, but a CECT of the abdomen reveals compression of the D3 segment of the duodenum due to narrowing of the angle of the superior mesenteric artery (SMA). Which of the following is the best option for treatment of this condition?", "options": [{"label": "A", "text": "Surgery to remove the obstruction", "correct": false}, {"label": "B", "text": "Administration of medications to relieve pain", "correct": false}, {"label": "C", "text": "Feeding the patient to promote weight gain", "correct": true}, {"label": "D", "text": "Endoscopic intervention to widen the narrowed angle", "correct": false}], "correct_answer": "C. Feeding the patient to promote weight gain", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Feeding the patient to promote weight gain</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Surgery to remove the obstruction . Surgical intervention may be considered if conservative measures fail . It is not the first line of treatment because the syndrome is often caused by a lack of mesenteric fat padding, not an actual physical obstruction that needs to be removed.</li><li>• Option A: Surgery to remove the obstruction</li><li>• Surgical intervention</li><li>• conservative measures fail</li><li>• not the first line of treatment</li><li>• Option B: Administration of medications to relieve pain . While pain management is an important aspect of patient care , medications alone will not address the underlying issue of the narrowed angle between the SMA and the aorta, which is causing the duodenal compression.</li><li>• Option B: Administration of medications to relieve pain</li><li>• pain management is an important aspect of patient care</li><li>• medications alone will not address the underlying issue</li><li>• Option D: Endoscopic intervention to widen the narrowed angle . Endoscopic intervention is not the standard treatment for SMA Syndrome because the problem is not within the duodenal lumen but rather external compression.</li><li>• Option D: Endoscopic intervention to widen the narrowed angle</li><li>• Endoscopic intervention</li><li>• not the standard treatment for SMA Syndrome</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The initial treatment for SMA Syndrome is conservative , focusing on nutritional support to promote weight gain and increase the mesenteric fat pad, thereby relieving the compression of the duodenum.</li><li>➤ initial treatment for SMA Syndrome is conservative</li><li>➤ SMA Syndrome , also known as Wilkie Syndrome , is a rare cause of intestinal obstruction . It occurs due to the narrowing of the angle between the superior mesenteric artery (SMA) and aorta, leading to compression of the third part of the duodenum (D3) .</li><li>➤ SMA Syndrome , also known as Wilkie Syndrome , is a rare cause of intestinal obstruction . It occurs due to the narrowing of the angle between the superior mesenteric artery (SMA) and aorta, leading to compression of the third part of the duodenum (D3) .</li><li>➤ SMA Syndrome</li><li>➤ Wilkie Syndrome</li><li>➤ rare cause of intestinal obstruction</li><li>➤ compression of the third part of the duodenum (D3)</li><li>➤ Risk factors:</li><li>➤ Risk factors:</li><li>➤ Sudden weight loss Anorexia nervosa Prolonged bed rest Scoliosis The clinical features of SMA Syndrome include colicky abdominal pain, bilious vomiting, and weight loss. On investigation, the small bowel appears normal, but a CECT of the abdomen may reveal compression of the D3 segment of the duodenum due to narrowing of the angle of the SMA. The initial treatment for SMA Syndrome is conservative and involves feeding the patient to promote weight gain and open the narrowed angle. This can be achieved through the placement of a naso-jejunostomy tube. If this fails, surgery may be required to bypass the duodenum and relieve the obstruction.</li><li>➤ Sudden weight loss</li><li>➤ Anorexia nervosa</li><li>➤ Prolonged bed rest</li><li>➤ Scoliosis</li><li>➤ The clinical features of SMA Syndrome include colicky abdominal pain, bilious vomiting, and weight loss. On investigation, the small bowel appears normal, but a CECT of the abdomen may reveal compression of the D3 segment of the duodenum due to narrowing of the angle of the SMA.</li><li>➤ CECT of the abdomen may reveal compression of the D3 segment of the duodenum</li><li>➤ The initial treatment for SMA Syndrome is conservative and involves feeding the patient to promote weight gain and open the narrowed angle. This can be achieved through the placement of a naso-jejunostomy tube. If this fails, surgery may be required to bypass the duodenum and relieve the obstruction.</li><li>➤ initial treatment for SMA Syndrome is conservative</li><li>➤ Ref : Online article: https://doi.org/10.53347/rID-11142</li><li>➤ Ref</li><li>➤ : Online article:</li><li>➤ https://doi.org/10.53347/rID-11142</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old male patient with a history of peptic ulcer disease presents with a complaint of non-bilious vomiting. On examination, a succussion splash is heard over abdomen. CECT reveals the presence of a pyloric stricture. Which of the following is the first step for management of this condition?", "options": [{"label": "A", "text": "Conservative management with nasogastric decompression and washout", "correct": true}, {"label": "B", "text": "Surgical reconstruction using Billroth II procedure", "correct": false}, {"label": "C", "text": "Endoscopic dilatation of the stricture", "correct": false}, {"label": "D", "text": "Mikulicz stricturoplasty to relieve the obstruction", "correct": false}], "correct_answer": "A. Conservative management with nasogastric decompression and washout", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Conservative management with nasogastric decompression and washout</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Surgical reconstruction using Billroth II procedure . The Billroth II procedure is a surgical option (gastro-jejunostomy) that is generally considered after conservative management has failed.</li><li>• Option B: Surgical reconstruction using Billroth II procedure</li><li>• surgical option</li><li>• generally considered after conservative management has failed.</li><li>• Option C: Endoscopic dilatation of the stricture . Endoscopic dilatation is a less invasive treatment option compared to surgery and can be effective in managing strictures . However, it is not the first-line treatment before attempting nasogastric decompression.</li><li>• Option C: Endoscopic dilatation of the stricture</li><li>• less invasive treatment option compared to surgery</li><li>• effective in managing strictures</li><li>• Option D: Mikulicz strictureplasty to relieve the obstruction . Mikulicz strictureplasty is a surgical technique used when strictures are not amenable to endoscopic dilatation . It is considered a more advanced step if other less invasive measures fail.</li><li>• Option D: Mikulicz strictureplasty to relieve the obstruction</li><li>• surgical technique used when strictures are not amenable to endoscopic dilatation</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The first step in managing a pyloric stricture is conservative management with nasogastric decompression and washout to provide symptomatic relief</li><li>➤ first step in managing a pyloric stricture</li><li>➤ conservative management</li><li>➤ nasogastric decompression</li><li>➤ Pyloric stricture is a late complication of peptic ulcer disease , which occurs due to the fibrosis and scarring that develop when the circumferential ulcers over the stomach heal. This can lead to narrowing of the stomach or gastric outlet obstruction, which usually occurs at the first part of the duodenum. Clinical features of pyloric stricture include a history of peptic ulcer disease and non-bilious vomiting . The management of pyloric stricture depends on the extent and severity of the obstruction . Initial conservative management involves nasogastric decompression and washout , which can provide symptomatic relief. Endoscopy can be used to confirm the presence of a stricture and to obtain a biopsy to rule out adenocarcinoma . If the stricture is benign, it can be treated with dilatation. If dilatation fails, surgery may be required to relieve the obstruction. Mikulicz stricturoplasty is a surgical procedure that involves opening the pylorus horizontally and closing it vertically to relieve the obstruction . This is a preferred option when the stricture is not amenable to endoscopic dilatation. Billroth II reconstruction is another surgical option that involves removal of the pylorus and reconstruction of the gastrointestinal tract to improve gastric emptying.</li><li>➤ Pyloric stricture is a late complication of peptic ulcer disease , which occurs due to the fibrosis and scarring that develop when the circumferential ulcers over the stomach heal. This can lead to narrowing of the stomach or gastric outlet obstruction, which usually occurs at the first part of the duodenum.</li><li>➤ Pyloric stricture is a late complication of peptic ulcer disease</li><li>➤ occurs due to the fibrosis</li><li>➤ scarring</li><li>➤ Clinical features of pyloric stricture include a history of peptic ulcer disease and non-bilious vomiting .</li><li>➤ Clinical features of pyloric stricture include a history of peptic ulcer disease and non-bilious vomiting</li><li>➤ The management of pyloric stricture depends on the extent and severity of the obstruction . Initial conservative management involves nasogastric decompression and washout , which can provide symptomatic relief.</li><li>➤ management of pyloric stricture</li><li>➤ extent and severity of the obstruction</li><li>➤ nasogastric decompression and washout</li><li>➤ Endoscopy can be used to confirm the presence of a stricture and to obtain a biopsy to rule out adenocarcinoma . If the stricture is benign, it can be treated with dilatation. If dilatation fails, surgery may be required to relieve the obstruction.</li><li>➤ Endoscopy</li><li>➤ confirm the presence of a stricture</li><li>➤ obtain a biopsy to rule out adenocarcinoma</li><li>➤ Mikulicz stricturoplasty is a surgical procedure that involves opening the pylorus horizontally and closing it vertically to relieve the obstruction . This is a preferred option when the stricture is not amenable to endoscopic dilatation. Billroth II reconstruction is another surgical option that involves removal of the pylorus and reconstruction of the gastrointestinal tract to improve gastric emptying.</li><li>➤ Mikulicz stricturoplasty is a surgical procedure that involves opening the pylorus horizontally and closing it vertically</li><li>➤ to relieve the obstruction</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1169</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1169</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 60-year-old male, a known case of chronic atrial fibrillation presents with acute abdominal pain and PR bleed. Abdominal examination revealed vague tenderness and diminished bowel sounds. Which of the following is the investigation of choice for diagnosis?", "options": [{"label": "A", "text": "Serum lipase", "correct": false}, {"label": "B", "text": "USG abdomen", "correct": false}, {"label": "C", "text": "X ray upper abdomen erect", "correct": false}, {"label": "D", "text": "CECT abdomen angiogram", "correct": true}], "correct_answer": "D. CECT abdomen angiogram", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) CECT abdomen angiogram</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Serum lipase. While serum lipase can be useful in diagnosing pancreatitis , it would not be the most helpful initial test for a patient suspected of having mesenteric ischemia.</li><li>• Option A: Serum lipase.</li><li>• serum lipase can be useful in diagnosing pancreatitis</li><li>• Option B: USG abdomen. An ultrasound of the abdomen can be useful for assessing many abdominal conditions, but it may not be the best choice for evaluating blood flow or identifying mesenteric ischemia, especially in an acute setting.</li><li>• Option B: USG abdomen.</li><li>• ultrasound of the abdomen can be useful for assessing many abdominal conditions,</li><li>• Option C: X-ray upper abdomen erect. An erect abdominal X-ray can show signs of bowel obstruction or free air under the diaphragm in cases of perforation but is not the most sensitive or specific test for mesenteric ischemia.</li><li>• Option C: X-ray upper abdomen erect.</li><li>• erect abdominal X-ray</li><li>• show signs of bowel obstruction or free air under the diaphragm</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ For a patient with suspected acute mesenteric ischemia , particularly in the context of chronic atrial fibrillation , the next best investigation is a CECT abdomen angiogram.</li><li>➤ suspected acute mesenteric ischemia</li><li>➤ context of chronic atrial fibrillation</li><li>➤ next best investigation is a CECT abdomen angiogram.</li><li>➤ SMA emboli may be carried from the left atrium in atrial fibrillation , the left ventricle after mural myocardial infarction , vegetations on mitral and aortic valves associated with endocarditis or an atheromatous plaque from an aortic aneurysm Investigation for mesenteric ischemia includes a CECT scan, which can determine whether the occlusion is acute or chronic and assess bowel viability or gangrene. Treatment for mesenteric ischemia depends on the extent and severity of the obstruction. Conservative management with antibiotics and bowel rest may be used in some cases. For acute occlusion, mesenteric vascular intervention is the preferred treatment . If there is evidence of gangrene, laparotomy and bowel resection may be required. Chronic mesenteric ischemia typically presents with mesenteric angina (central abdominal pain) and diarrhoea. A CECT angiogram can reveal atherosclerosis of the mesentery. Treatment for chronic mesenteric ischemia involves mesenteric angioplasty bypass.</li><li>➤ SMA emboli may be carried from the left atrium in atrial fibrillation , the left ventricle after mural myocardial infarction , vegetations on mitral and aortic valves associated with endocarditis or an atheromatous plaque from an aortic aneurysm</li><li>➤ SMA emboli</li><li>➤ left atrium in atrial fibrillation</li><li>➤ left ventricle after mural myocardial infarction</li><li>➤ vegetations on mitral and aortic valves</li><li>➤ endocarditis</li><li>➤ atheromatous plaque</li><li>➤ Investigation for mesenteric ischemia includes a CECT scan, which can determine whether the occlusion is acute or chronic and assess bowel viability or gangrene. Treatment for mesenteric ischemia depends on the extent and severity of the obstruction. Conservative management with antibiotics and bowel rest may be used in some cases.</li><li>➤ For acute occlusion, mesenteric vascular intervention is the preferred treatment . If there is evidence of gangrene, laparotomy and bowel resection may be required.</li><li>➤ For acute occlusion, mesenteric vascular intervention is the preferred treatment</li><li>➤ Chronic mesenteric ischemia typically presents with mesenteric angina (central abdominal pain) and diarrhoea. A CECT angiogram can reveal atherosclerosis of the mesentery. Treatment for chronic mesenteric ischemia involves mesenteric angioplasty bypass.</li><li>➤ Treatment for chronic mesenteric ischemia involves mesenteric angioplasty bypass.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1312-1313</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1312-1313</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "What is the management protocol for enterocutaneous fistula?", "options": [{"label": "A", "text": "Sepsis control and skin care, TPN, CECT, and planned repair", "correct": true}, {"label": "B", "text": "Antibiotics, enteral nutrition, MRI, and surgical intervention", "correct": false}, {"label": "C", "text": "Conservative management, low-residue diet, ultrasound, and outpatient follow-up", "correct": false}, {"label": "D", "text": "Bowel rest, antibiotics, barium enema, and observation", "correct": false}], "correct_answer": "A. Sepsis control and skin care, TPN, CECT, and planned repair", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Sepsis control and skin care, TPN, CECT, and planned repair</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Antibiotics, enteral nutrition, MRI, and surgical intervention . While antibiotics and surgical intervention may be part of the management , enteral nutrition may not be feasible with a high-output fistula, and MRI is not the standard imaging modality for this condition.</li><li>• Option B: Antibiotics, enteral nutrition, MRI, and surgical intervention</li><li>• antibiotics</li><li>• surgical intervention</li><li>• management</li><li>• enteral nutrition</li><li>• not be feasible</li><li>• Option C: Conservative management, low-residue diet, ultrasound, and outpatient follow-up . Conservative management may be indicated in some cases , but this option lacks the aggressive approach often required for enterocutaneous fistulas, such as TPN and detailed imaging.</li><li>• Option C: Conservative management, low-residue diet, ultrasound, and outpatient follow-up</li><li>• Conservative management</li><li>• indicated in some cases</li><li>• Option D: Bowel rest, antibiotics, barium enema, and observation . Bowel rest and observation are part of the initial management , but merely antibiotics might not be sufficient for sepsis control , and a barium enema is not typically used for fistula assessment due to the risk of extravasation and worsening sepsis.</li><li>• Option D: Bowel rest, antibiotics, barium enema, and observation</li><li>• Bowel rest</li><li>• observation</li><li>• part of the initial management</li><li>• antibiotics might not be sufficient for sepsis control</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The management protocol for enterocutaneous fistula involves sepsis control, skin care, total parenteral nutrition (TPN), anatomical delineation with a CECT scan , and planned surgical repair following the SNAP protocol.</li><li>➤ management protocol for enterocutaneous fistula</li><li>➤ sepsis control, skin care, total parenteral nutrition</li><li>➤ anatomical delineation with a CECT scan</li><li>➤ planned surgical repair</li><li>➤ Enterocutaneous fistula is an abnormal communication between the bowel and the skin, which can be caused by postoperative complications, Crohn's disease, GI malignancies, or radiation enteritis . The management of enterocutaneous fistula is based on the SNAP protocol . Sepsis control and skin care are essential for the management of enterocutaneous fistula, along with total parenteral nutrition (TPN) to provide adequate nutrition. Anatomical delineation, typically through a CECT scan, is necessary to identify the extent of the fistula and plan for repair. Planned repair is the ultimate goal of management, but high-output fistulas (&gt;500ml) may not close spontaneously , and additional interventions may be required. Conservative management, a low-residue diet, and ultrasound are not effective for managing enterocutaneous fistula, and surgical intervention is required for definitive treatment.</li><li>➤ Enterocutaneous fistula is an abnormal communication between the bowel and the skin, which can be caused by postoperative complications, Crohn's disease, GI malignancies, or radiation enteritis . The management of enterocutaneous fistula is based on the SNAP protocol .</li><li>➤ Enterocutaneous fistula</li><li>➤ caused by postoperative complications, Crohn's disease, GI malignancies, or radiation enteritis</li><li>➤ SNAP protocol</li><li>➤ Sepsis control and skin care are essential for the management of enterocutaneous fistula, along with total parenteral nutrition (TPN) to provide adequate nutrition. Anatomical delineation, typically through a CECT scan, is necessary to identify the extent of the fistula and plan for repair.</li><li>➤ Anatomical delineation, typically through a CECT scan, is necessary to identify the extent of the fistula and plan for repair.</li><li>➤ Planned repair is the ultimate goal of management, but high-output fistulas (&gt;500ml) may not close spontaneously , and additional interventions may be required. Conservative management, a low-residue diet, and ultrasound are not effective for managing enterocutaneous fistula, and surgical intervention is required for definitive treatment.</li><li>➤ high-output fistulas (&gt;500ml) may not close spontaneously</li><li>➤ Principles of management of enterocutaneous fistulae (SNAP)</li><li>➤ Principles of management of enterocutaneous fistulae (SNAP)</li><li>➤ S - elimination of S epsis and S kin protection</li><li>➤ S</li><li>➤ S</li><li>➤ S</li><li>➤ N - N utrition – a period of parenteral nutrition may well be required</li><li>➤ N</li><li>➤ N</li><li>➤ A - A natomical assessment</li><li>➤ A</li><li>➤ A</li><li>➤ P - definitive P lanned surgery</li><li>➤ P</li><li>➤ P</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1315-16</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28 th Ed. Pg 1315-16</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old patient underwent surgery for colon cancer, and a transverse colostomy was created. Which of the following complications is the patient unlikely to experience?", "options": [{"label": "A", "text": "Excoriation of surrounding skin is more common than ileostomy", "correct": true}, {"label": "B", "text": "Loop stomas are usually done for temporary indications", "correct": false}, {"label": "C", "text": "Loop ileostomy is easier to construct than loop transverse colostomy", "correct": false}, {"label": "D", "text": "Ileostomy is spouted, whereas colostomy is flushed with the skin", "correct": false}], "correct_answer": "A. Excoriation of surrounding skin is more common than ileostomy", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/15/screenshot-2024-03-15-115155.jpg"], "explanation": "<p><strong>Ans. A) Excoriation of surrounding skin is more common than ileostomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Temporary or defunctioning stomas are usually fashioned as loop stomas .</li><li>• Option B:</li><li>• defunctioning stomas</li><li>• fashioned as loop stomas</li><li>• Option C: The advantage of a loop ileostomy over a loop colostomy is the ease with which the bowel can be brought to the surface .</li><li>• Option C:</li><li>• loop ileostomy over a loop colostomy</li><li>• ease with which the bowel can be brought to the surface</li><li>• Option D: An ileostomy is spouted ; a colostomy is flush because the ileostomy effluent is usually liquid , whereas colostomy effluent is usually solid . The spouts permit easier drainage of the secretions.</li><li>• Option D:</li><li>• ileostomy is spouted</li><li>• colostomy is flush because the ileostomy effluent is usually liquid</li><li>• colostomy effluent is usually solid</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• INTESTINAL STOMA:</li><li>• INTESTINAL STOMA:</li><li>• It is the surgical exteriorization of a portion of the small bowel or colon . In this case, the patient underwent surgery for colon cancer, and a transverse colostomy was created. Stoma creation is indicated to protect anastomosis and for intestinal obstruction.</li><li>• It is the surgical exteriorization of a portion of the small bowel or colon . In this case, the patient underwent surgery for colon cancer, and a transverse colostomy was created. Stoma creation is indicated to protect anastomosis and for intestinal obstruction.</li><li>• surgical exteriorization of a portion of the small bowel or colon</li><li>• Stoma creation</li><li>• protect anastomosis and for intestinal obstruction.</li><li>• Ref : Bailey and Love, 28 th Ed. Pg 1313-14.</li><li>• Ref</li><li>• : Bailey and Love, 28 th Ed. Pg 1313-14.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 30-year-old male, non-smoker presented with intermittent dysphagia for the past 3 months. Barium swallow showed the following characteristic appearance. What is the most probable diagnosis?", "options": [{"label": "A", "text": "Achalasia cardia", "correct": false}, {"label": "B", "text": "Plummer Vinson syndrome", "correct": false}, {"label": "C", "text": "Schatzki ring", "correct": true}, {"label": "D", "text": "Ca esophagus", "correct": false}], "correct_answer": "C. Schatzki ring", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/untitled-589.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Achalasia cardia. Achalasia cardia typically presents with a dilated esophagus and a \"bird's beak\" narrowing at the gastroesophageal junction. The absence of normal peristalsis in the body of the esophagus is also characteristic.</li><li>• Option A: Achalasia cardia.</li><li>• Achalasia cardia</li><li>• dilated esophagus and a \"bird's beak\" narrowing at the gastroesophageal junction.</li><li>• Option B: Plummer Vinson syndrome. Plummer Vinson syndrome is associated with upper esophageal webs and iron deficiency anemia. Barium swallow may show thin web-like structures in the upper esophagus.</li><li>• Option B: Plummer Vinson syndrome.</li><li>• associated with upper esophageal webs and iron deficiency anemia.</li><li>• Option D: Ca Esophagus. Esophageal cancer can present with various findings on a barium swallow, including irregular or nodular filling defects, luminal narrowing, and possibly evidence of tumor invasion . It does not typically present as a thin circumferential ring.</li><li>• Option D: Ca Esophagus.</li><li>• present with various findings on a barium swallow, including irregular or nodular filling defects, luminal narrowing, and possibly evidence of tumor invasion</li><li>• The description of the image suggests that the most likely diagnosis is a Schatzki ring, as it is characterized by a thin circumferential ring in the distal esophagus.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ A Schatzki ring , presenting as a thin circumferential constriction at the gastroesophageal junction on a barium swallow , is the most probable diagnosis in a patient with intermittent dysphagia.</li><li>➤ Schatzki ring</li><li>➤ thin circumferential constriction</li><li>➤ gastroesophageal junction on a barium swallow</li><li>➤ Schatzki ring is a benign condition There is a concentric, fibrous thickening and narrowing of the gastro-esophageal junction (GEJ), with squamous epithelium above and columnar cells below. Most common presentation - Dysphagia (if diameter &lt; 13mm) and gastro-esophageal reflux disorder (GERD). Most common site - lower third of the esophagus. Treatment is endoscopic dilation with anti-reflux therapy</li><li>➤ Schatzki ring is a benign condition</li><li>➤ benign condition</li><li>➤ There is a concentric, fibrous thickening and narrowing of the gastro-esophageal junction (GEJ), with squamous epithelium above and columnar cells below.</li><li>➤ Most common presentation - Dysphagia (if diameter &lt; 13mm) and gastro-esophageal reflux disorder (GERD).</li><li>➤ Most common presentation -</li><li>➤ Most common site - lower third of the esophagus.</li><li>➤ Most common site -</li><li>➤ Treatment is endoscopic dilation with anti-reflux therapy</li><li>➤ Treatment is endoscopic dilation with anti-reflux therapy</li><li>➤ Ref : Bailey and Love's Short Practice of Surgery 28th Edition pg 1147</li><li>➤ Ref</li><li>➤ : Bailey and Love's Short Practice of Surgery 28th Edition pg 1147</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A young schizophrenic female presents with abdominal pain and vomiting. The surgeon notices that she has scanty hair on scalp, and on palpation of abdomen there is crepitus in the stomach. She is likely to be suffering from?", "options": [{"label": "A", "text": "Phytobezoar", "correct": false}, {"label": "B", "text": "Trichobezoar", "correct": true}, {"label": "C", "text": "Ca stomach", "correct": false}, {"label": "D", "text": "Gastric volvulus", "correct": false}], "correct_answer": "B. Trichobezoar", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Trichobezoar</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Phytobezoar. Phytobezoars are composed of indigestible plant material and are typically found in patients with impaired gastric motility , often secondary to gastric surgery, and not necessarily associated with psychiatric conditions or hair ingestion.</li><li>• Option A: Phytobezoar.</li><li>• composed of indigestible plant material and are typically found in patients with impaired gastric motility</li><li>• Option C: Ca stomach. Gastric cancer (Ca stomach) could present with abdominal pain and vomiting but would not typically present with crepitus in the stomach or be associated with the ingestion of hair.</li><li>• Option C: Ca stomach.</li><li>• Gastric cancer</li><li>• present with abdominal pain and vomiting but would not typically present with crepitus</li><li>• Option D: Gastric volvulus. Gastric volvulus presents with acute abdominal pain and may lead to vomiting, but it is unlikely to be associated with hair ingestion or crepitus on abdominal palpation unless there is associated gastric strangulation and perforation, which is a medical emergency.</li><li>• Option D: Gastric volvulus.</li><li>• acute abdominal pain and may lead to vomiting, but it is unlikely to be associated with hair ingestion or crepitus on abdominal palpation</li><li>• The clinical picture provided most consistently aligns with a trichobezoar , given the patient's psychiatric history and the specific finding of crepitus in the stomach on palpation.</li><li>• trichobezoar</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In a young psychiatric patient presenting with abdominal pain, vomiting, and evidence of scanty scalp hair, along with palpable crepitus in the stomach, the likely diagnosis is a trichobezoar.</li><li>➤ Trichobezoar (hair balls) are unusual and are virtually exclusively found in young psychiatric patients. It is caused by the ingestion of hair, which remains undigested in the stomach. The hair ball can lead to ulceration and gastrointestinal bleeding, perforation or obstruction . The diagnosis is made easily at endoscopy. Treatment consists of removal of the bezoar, which may require open surgical treatment. Phytobezoars are made of vegetable matter and are found principally in patients who have gastric stasis, usually following gastric surgery.</li><li>➤ Trichobezoar (hair balls) are unusual and are virtually exclusively found in young psychiatric patients.</li><li>➤ Trichobezoar</li><li>➤ It is caused by the ingestion of hair, which remains undigested in the stomach.</li><li>➤ The hair ball can lead to ulceration and gastrointestinal bleeding, perforation or obstruction .</li><li>➤ The hair ball can lead to ulceration and gastrointestinal bleeding, perforation or obstruction</li><li>➤ The diagnosis is made easily at endoscopy.</li><li>➤ Treatment consists of removal of the bezoar, which may require open surgical treatment.</li><li>➤ Phytobezoars are made of vegetable matter and are found principally in patients who have gastric stasis, usually following gastric surgery.</li><li>➤ Ref : Bailey and Love's Short Practice of Surgery 28th Edition pg 1180</li><li>➤ Ref</li><li>➤ : Bailey and Love's Short Practice of Surgery 28th Edition pg 1180</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of these are a part of Borchardt’s triad seen in gastric volvulus except?", "options": [{"label": "A", "text": "Acute epigastric pain", "correct": false}, {"label": "B", "text": "Abdominal distension", "correct": true}, {"label": "C", "text": "Vomiting", "correct": false}, {"label": "D", "text": "Inability to pass Ryle’s tube", "correct": false}], "correct_answer": "B. Abdominal distension", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Abdominal distension</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Borchardt’s triad is a classical clinical presentation associated with gastric volvulus , which is a rotation of the stomach by more than 180 degrees, creating a closed-loop obstruction that can compromise the blood supply . The triad includes the following components:</li><li>• Borchardt’s triad</li><li>• classical clinical presentation</li><li>• gastric volvulus</li><li>• rotation of the stomach</li><li>• more than 180 degrees,</li><li>• closed-loop obstruction</li><li>• compromise the blood supply</li><li>• Option A: Acute epigastric pain . Patients typically present with sudden onset of severe epigastric pain due to the rotation of the stomach and potential compromise of its blood supply.</li><li>• Option A: Acute epigastric pain</li><li>• present with sudden onset of severe epigastric pain due to the rotation of the stomach</li><li>• Option C: Vomiting . Vomiting or retching is a common feature due to the obstruction of the GI tract . However, in some cases of complete volvulus, vomiting may not be possible as the rotation prevents gastric emptying.</li><li>• Option C: Vomiting</li><li>• retching is a common feature due to the obstruction of the GI tract</li><li>• Option D: Inability to pass Ryle’s tube . The inability to pass a nasogastric tube (Ryle’s tube) into the stomach is due to the physical obstruction created by the volvulus , and it is a classic sign of this condition.</li><li>• Option D: Inability to pass Ryle’s tube</li><li>• inability to pass a nasogastric tube</li><li>• into the stomach is due to the physical obstruction</li><li>• volvulus</li><li>• Ref : Bailey and Love, 28 th Ed. Pg 1180-81</li><li>• Ref</li><li>• : Bailey and Love, 28 th Ed. Pg 1180-81</li><li>• Online reference https://radiopaedia.org/articles/borchardts-triad-gastric-volvulus</li><li>• Online reference</li><li>• https://radiopaedia.org/articles/borchardts-triad-gastric-volvulus</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 49 years old male presents with long-standing vague abdominal symptoms, early satiety, episodic abdominal pain, associated with vomiting. His imaging shows the following picture. What is the condition he is suffering from?", "options": [{"label": "A", "text": "Gastric volvulus", "correct": false}, {"label": "B", "text": "Ca stomach", "correct": false}, {"label": "C", "text": "SMA syndrome", "correct": true}, {"label": "D", "text": "Gastric ulcer", "correct": false}], "correct_answer": "C. SMA syndrome", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/09/16/image.png"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/24/surgery.jpg"], "explanation": "<p><strong>Ans. C) SMA syndrome</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Gastric volvulus . Gastric volvulus is an abnormal rotation of the stomach, which would typically show a distended stomach with an abnormal orientation on imaging . It often presents acutely with severe abdominal pain and retching without vomitus.</li><li>• Option A: Gastric volvulus</li><li>• abnormal rotation of the stomach, which would typically show a distended stomach with an abnormal orientation on imaging</li><li>• Option B: Ca stomach . Cancer of the stomach may present with nonspecific symptoms like weight loss, early satiety, and possibly a mass or irregularity on imaging , but it does not typically cause the acute angulation of the SMA leading to duodenal compression.</li><li>• Option B: Ca stomach</li><li>• present with nonspecific symptoms like weight loss, early satiety, and possibly a mass or irregularity on imaging</li><li>• Option D: Gastric ulcer . A gastric ulcer may present with abdominal pain and symptoms related to eating , but it would not cause the compression of the duodenum as seen in SMA syndrome.</li><li>• Option D: Gastric ulcer</li><li>• gastric ulcer</li><li>• abdominal pain</li><li>• symptoms related to eating</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In a patient presenting with chronic vague abdominal symptoms, early satiety, and vomiting, along with imaging showing compression of the third part of the duodenum by the SMA, the diagnosis is likely Superior Mesenteric Artery Syndrome.</li><li>➤ Superior mesenteric artery (SMA) syndrome , also known as Wilkie syndrome is a rare acquired vascular compression disorder in which acute angulation of the superior mesenteric artery (SMA) results in compression of the third part of the duodenum, leading to obstruction. Patients with SMA syndrome may present acutely, with chronic insidious symptomatology, or with an acute exacerbation of chronic symptoms: Acute presentation is usually characterised by signs and symptoms of duodenal obstruction Chronic cases may present with long-standing vague abdominal symptoms, early satiety and anorexia, or recurrent episodes of abdominal pain, associated with vomiting.</li><li>➤ Superior mesenteric artery (SMA) syndrome , also known as Wilkie syndrome is a rare acquired vascular compression disorder in which acute angulation of the superior mesenteric artery (SMA) results in compression of the third part of the duodenum, leading to obstruction.</li><li>➤ Superior mesenteric artery (SMA) syndrome , also known as Wilkie syndrome is a rare acquired vascular compression disorder in which acute angulation of the superior mesenteric artery (SMA) results in compression of the third part of the duodenum, leading to obstruction.</li><li>➤ Superior mesenteric artery (SMA) syndrome</li><li>➤ Wilkie syndrome</li><li>➤ acute angulation of the superior mesenteric artery (SMA)</li><li>➤ Patients with SMA syndrome may present acutely, with chronic insidious symptomatology, or with an acute exacerbation of chronic symptoms:</li><li>➤ Patients with SMA syndrome may present acutely, with chronic insidious symptomatology, or with an acute exacerbation of chronic symptoms:</li><li>➤ Acute presentation is usually characterised by signs and symptoms of duodenal obstruction</li><li>➤ Acute presentation is usually characterised by signs and symptoms of duodenal obstruction</li><li>➤ Acute presentation</li><li>➤ Chronic cases may present with long-standing vague abdominal symptoms, early satiety and anorexia, or recurrent episodes of abdominal pain, associated with vomiting.</li><li>➤ Chronic cases may present with long-standing vague abdominal symptoms, early satiety and anorexia, or recurrent episodes of abdominal pain, associated with vomiting.</li><li>➤ Chronic cases</li><li>➤ Management:</li><li>➤ Management:</li><li>➤ Medical management - including decompression of the stomach and duodenum with a nasogastric tube , correction of nutritional and electrolytes deficiencies , through TPN , or preferably, if possible, enteral feeding with a naso-jejunal tube past the point of compression, which fulfils nutritional requirements while avoiding the complications of TPN. Surgical management - Duodenojejunostomy.</li><li>➤ Medical management - including decompression of the stomach and duodenum with a nasogastric tube , correction of nutritional and electrolytes deficiencies , through TPN , or preferably, if possible, enteral feeding with a naso-jejunal tube past the point of compression, which fulfils nutritional requirements while avoiding the complications of TPN.</li><li>➤ Medical management - including decompression of the stomach and duodenum with a nasogastric tube , correction of nutritional and electrolytes deficiencies , through TPN , or preferably, if possible, enteral feeding with a naso-jejunal tube past the point of compression, which fulfils nutritional requirements while avoiding the complications of TPN.</li><li>➤ Medical management -</li><li>➤ decompression of the stomach and duodenum with a nasogastric tube</li><li>➤ correction of nutritional and electrolytes deficiencies</li><li>➤ through TPN</li><li>➤ Surgical management - Duodenojejunostomy.</li><li>➤ Surgical management - Duodenojejunostomy.</li><li>➤ Surgical management -</li><li>➤ Duodenojejunostomy.</li><li>➤ Ref : Online reference https://radiopaedia.org/articles/superior-mesenteric-artery syndrome#:~:text=Superior%20mesenteric%20artery%20(SMA)%20syndrome,part%20of%20the%20duodenum%2C%20leading</li><li>➤ Ref : Online reference</li><li>➤ https://radiopaedia.org/articles/superior-mesenteric-artery syndrome#:~:text=Superior%20mesenteric%20artery%20(SMA)%20syndrome,part%20of%20the%20duodenum%2C%20leading</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of these are a part of Mackler’s triad except?", "options": [{"label": "A", "text": "Pain", "correct": false}, {"label": "B", "text": "Fever", "correct": true}, {"label": "C", "text": "Vomiting", "correct": false}, {"label": "D", "text": "Subcutaneous emphysema", "correct": false}], "correct_answer": "B. Fever", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/03/untitled-591.jpg"], "explanation": "<p><strong>Ans. B) Fever</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Pain . Pain, especially sudden severe chest pain , is a key feature of Mackler’s triad . It is typically retrosternal , exacerbated by swallowing , and may radiate to the back.</li><li>• Option A: Pain</li><li>• sudden severe chest pain</li><li>• Mackler’s triad</li><li>• retrosternal</li><li>• exacerbated by swallowing</li><li>• Option C: Vomiting . Vomiting is a part of Mackler’s triad and is often the precipitating event leading to esophageal rupture in Boerhaave’s syndrome .</li><li>• Option C: Vomiting</li><li>• Mackler’s triad</li><li>• precipitating event leading to esophageal rupture</li><li>• Boerhaave’s syndrome</li><li>• Option D: Subcutaneous emphysema . Subcutaneous emphysema, which is air present in the subcutaneous tissue , can occur as a result of esophageal perforation with air escaping into the surrounding tissue . It is the third component of Mackler's triad.</li><li>• Option D: Subcutaneous emphysema</li><li>• air present in the subcutaneous tissue</li><li>• result of esophageal perforation with air escaping into the surrounding tissue</li><li>• The correct answer to the question is Option B: Fever , as it is not part of Mackler’s triad.</li><li>• Option B: Fever</li><li>• not part of Mackler’s triad.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Mackler’s triad , indicative of Boerhaave’s syndrome , includes vomiting, pain, and subcutaneous emphysema , but not fever .</li><li>➤ Mackler’s triad</li><li>➤ Boerhaave’s syndrome</li><li>➤ vomiting, pain, and subcutaneous emphysema</li><li>➤ not fever</li><li>➤ Spontaneous emetogenic perforation (Boerhaave’s syndrome) results from a sudden increase in oesophageal pressure against a closed glottis from vomiting. Mackler’s triad is a feature of Boerhaave’s syndrome.</li><li>➤ Spontaneous emetogenic perforation (Boerhaave’s syndrome) results from a sudden increase in oesophageal pressure against a closed glottis from vomiting.</li><li>➤ Spontaneous emetogenic perforation (Boerhaave’s syndrome) results from a sudden increase in oesophageal pressure against a closed glottis from vomiting.</li><li>➤ Spontaneous emetogenic perforation (Boerhaave’s syndrome)</li><li>➤ sudden increase in oesophageal pressure against a closed glottis</li><li>➤ Mackler’s triad is a feature of Boerhaave’s syndrome.</li><li>➤ Mackler’s triad is a feature of Boerhaave’s syndrome.</li><li>➤ Typically, the site of perforation is the lower oesophagus towards the left pleural cavity . Hamman’s sign refers to a crunching sound on auscultation of the heart owing to surgical emphysema. Because of high septic load, urgent surgical intervention is usually required.</li><li>➤ Typically, the site of perforation is the lower oesophagus towards the left pleural cavity .</li><li>➤ Typically, the site of perforation is the lower oesophagus towards the left pleural cavity .</li><li>➤ site of perforation is the lower oesophagus towards the left pleural cavity</li><li>➤ Hamman’s sign refers to a crunching sound on auscultation of the heart owing to surgical emphysema.</li><li>➤ Hamman’s sign refers to a crunching sound on auscultation of the heart owing to surgical emphysema.</li><li>➤ Hamman’s sign</li><li>➤ Because of high septic load, urgent surgical intervention is usually required.</li><li>➤ Because of high septic load, urgent surgical intervention is usually required.</li><li>➤ Ref : Bailey and Love's Short Practice of Surgery 28th Edition pg 1127</li><li>➤ Ref : Bailey and Love's Short Practice of Surgery 28th Edition pg 1127</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is incorrect about caustic injury to upper gastro intestinal tract?", "options": [{"label": "A", "text": "Alkali ingestion is more dangerous", "correct": false}, {"label": "B", "text": "Zargar’s grading is used for severity of injury", "correct": false}, {"label": "C", "text": "It is a premalignant condition", "correct": false}, {"label": "D", "text": "Multiple esophageal ulcers warrant urgent cervical esophagostomy", "correct": true}], "correct_answer": "D. Multiple esophageal ulcers warrant urgent cervical esophagostomy", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/15/screenshot-2024-03-15-122231.jpg"], "explanation": "<p><strong>Ans. D) Multiple esophageal ulcers warrant urgent cervical esophagostomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Alkali ingestion is more dangerous . Ingestion of alkali substances is indeed more dangerous compared to acids because alkalis cause liquefactive necrosis , allowing deeper tissue penetration and damage which can lead to more severe complications such as perforation.</li><li>• Option A: Alkali ingestion is more dangerous</li><li>• Ingestion of alkali substances</li><li>• dangerous compared to acids because alkalis cause liquefactive necrosis</li><li>• deeper tissue penetration</li><li>• Option B: Zargar’s grading is used for severity of injury . Zargar’s grading system is a well-established scale used to classify the severity of caustic injuries to the esophagus based on endoscopic findings , helping to guide treatment decisions.</li><li>• Option B: Zargar’s grading is used for severity of injury</li><li>• Zargar’s grading system</li><li>• well-established scale</li><li>• classify the severity of caustic injuries</li><li>• esophagus based on endoscopic findings</li><li>• Option C: It is a premalignant condition . Chronic injury from caustic ingestion can lead to esophageal strictures , which are a known risk factor for the development of esophageal cancer , thus making it a premalignant condition.</li><li>• Option C: It is a premalignant condition</li><li>• Chronic injury</li><li>• caustic ingestion</li><li>• esophageal strictures</li><li>• risk factor for the development of esophageal cancer</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In the context of caustic injuries to the upper gastrointestinal tract , while alkali ingestion is indeed more dangerous, and Zargar’s grading is used to assess the severity of injury , and such injuries can be premalignant , the presence of multiple esophageal ulcers does not universally warrant an urgent cervical esophagostomy.</li><li>➤ caustic injuries to the upper gastrointestinal tract</li><li>➤ alkali ingestion is indeed more dangerous,</li><li>➤ Zargar’s grading is used to assess the severity of injury</li><li>➤ injuries can be premalignant</li><li>➤ presence of multiple esophageal ulcers does not universally warrant an urgent cervical esophagostomy.</li><li>➤ The substance ingested can be a strong acid, causing coagulative necrosis with eschar formation , which may limit penetration to deeper layers, or strong alkali, leading to liquefactive necrosis . The latter potentially penetrates deeper into the oesophageal wall, producing a more severe injury pattern. It is a premalignant condition - Delayed complications include stricture and malignancy. Treatment - Most caustic injuries can be managed conservatively with supportive measures. Deterioration requires surgical treatment, with emergency esophagectomy. The oesophagus can be mobilised transhiatally or via a thoracoscopic approach. Immediate reconstruction is not recommended . A cervical oesophagostomy and a gastrostomy can be done and future reconstruction planned. A feeding jejunostomy is an alternative for nutritional support if the stomach also requires resection.</li><li>➤ The substance ingested can be a strong acid, causing coagulative necrosis with eschar formation , which may limit penetration to deeper layers, or strong alkali, leading to liquefactive necrosis . The latter potentially penetrates deeper into the oesophageal wall, producing a more severe injury pattern.</li><li>➤ strong acid, causing</li><li>➤ coagulative necrosis with eschar formation</li><li>➤ strong alkali, leading to liquefactive necrosis</li><li>➤ It is a premalignant condition - Delayed complications include stricture and malignancy.</li><li>➤ premalignant condition</li><li>➤ Treatment - Most caustic injuries can be managed conservatively with supportive measures. Deterioration requires surgical treatment, with emergency esophagectomy. The oesophagus can be mobilised transhiatally or via a thoracoscopic approach. Immediate reconstruction is not recommended . A cervical oesophagostomy and a gastrostomy can be done and future reconstruction planned. A feeding jejunostomy is an alternative for nutritional support if the stomach also requires resection.</li><li>➤ Treatment -</li><li>➤ Immediate reconstruction is not recommended</li><li>➤ Ref : Bailey and Love's Short Practice of Surgery 28th Edition pg 1129</li><li>➤ Ref</li><li>➤ : Bailey and Love's Short Practice of Surgery 28th Edition pg 1129</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these food groups is avoided in patients with irritable bowel syndrome?", "options": [{"label": "A", "text": "Rice", "correct": false}, {"label": "B", "text": "Dairy", "correct": false}, {"label": "C", "text": "FODMAP group", "correct": true}, {"label": "D", "text": "High glycemic index foods", "correct": false}], "correct_answer": "C. FODMAP group", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/15/screenshot-2024-03-15-122623.png"], "explanation": "<p><strong>Ans. C) FODMAP group</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is a true statement(s) about capsule endoscopy? It involves swallowing a small camera capsule that takes pictures of the digestive tract. It is used to diagnose conditions such as Crohn's disease and small intestine tumors. The capsule is disposable and does not need to be retrieved after the procedure. It is an invasive procedure that requires sedation.", "options": [{"label": "A", "text": "1 and 2", "correct": false}, {"label": "B", "text": "2 and 3", "correct": false}, {"label": "C", "text": "1 and 3", "correct": false}, {"label": "D", "text": "1,2 and 3", "correct": true}], "correct_answer": "D. 1,2 and 3", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) 1,2 and 3</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Capsule endoscopy:</li><li>• Capsule endoscopy:</li><li>• It involves swallowing a small camera capsule that takes pictures of the digestive tract - This is a true statement about capsule endoscopy. The camera capsule is about the size of a large vitamin pill and contains a tiny camera and light source. The patient swallows the capsule, which then takes pictures of the digestive tract as it passes through the body. It is used to diagnose conditions such as Crohn's disease and small intestine tumors - This is also a true statement about capsule endoscopy. The procedure is typically used to diagnose conditions that affect the small intestine, such as Crohn's disease, celiac disease, and small intestine tumors. The capsule is disposable and does not need to be retrieved after the procedure - This is another true statement about capsule endoscopy. The camera capsule is disposable and does not need to be retrieved after the procedure. It is passed out of the body in the stool and can be safely disposed of. It is an invasive procedure that requires sedation - This statement is not true. Capsule endoscopy is a non-invasive procedure that does not require sedation . The patient can go about their normal activities during the procedure, although they may be asked to avoid certain foods and medications before and after the procedure.</li><li>• It involves swallowing a small camera capsule that takes pictures of the digestive tract - This is a true statement about capsule endoscopy. The camera capsule is about the size of a large vitamin pill and contains a tiny camera and light source. The patient swallows the capsule, which then takes pictures of the digestive tract as it passes through the body.</li><li>• camera capsule is about the size of a large vitamin pill</li><li>• It is used to diagnose conditions such as Crohn's disease and small intestine tumors - This is also a true statement about capsule endoscopy. The procedure is typically used to diagnose conditions that affect the small intestine, such as Crohn's disease, celiac disease, and small intestine tumors.</li><li>• used to diagnose conditions that affect the small intestine, such as Crohn's disease, celiac disease, and small intestine tumors.</li><li>• The capsule is disposable and does not need to be retrieved after the procedure - This is another true statement about capsule endoscopy. The camera capsule is disposable and does not need to be retrieved after the procedure. It is passed out of the body in the stool and can be safely disposed of.</li><li>• It is an invasive procedure that requires sedation - This statement is not true. Capsule endoscopy is a non-invasive procedure that does not require sedation . The patient can go about their normal activities during the procedure, although they may be asked to avoid certain foods and medications before and after the procedure.</li><li>• not true. Capsule endoscopy is a non-invasive procedure that does not require sedation</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Capsule endoscopy is a non-invasive diagnostic procedure that involves swallowing a small camera to take images of the digestive tract . It is used to diagnose conditions such as Crohn's disease and small intestine tumors , and the capsule is disposable , exiting the body naturally without the need for retrieval or sedation .</li><li>➤ Capsule endoscopy</li><li>➤ non-invasive diagnostic procedure</li><li>➤ swallowing a small camera to take images of the digestive tract</li><li>➤ diagnose conditions such as Crohn's disease</li><li>➤ small intestine tumors</li><li>➤ capsule is disposable</li><li>➤ exiting the body naturally without the need for retrieval or sedation</li><li>➤ Ref : Bailey and Love, 28th Ed. Pg 153</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28th Ed. Pg 153</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following statements is true regarding hemobilia? It is a rare condition where blood flows into the biliary tree. It is commonly caused by gallstones or inflammation of the gallbladder. Symptoms may include abdominal pain, jaundice, and Malena. Diagnosis is usually made through a liver biopsy.", "options": [{"label": "A", "text": "1 and 3", "correct": true}, {"label": "B", "text": "2 and 4", "correct": false}, {"label": "C", "text": "1,2, and 3", "correct": false}, {"label": "D", "text": "1 and 4", "correct": false}], "correct_answer": "A. 1 and 3", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A. 1 and 3</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• It is a rare condition where blood flows into the biliary tree - This statement is true. Hemobilia is a rare condition where bleeding occurs into the biliary tree . It is commonly caused by gallstones or inflammation of the gallbladder - This statement is not true. While gallstones or inflammation of the gallbladder can cause bleeding into the biliary tree, hemobilia is typically caused by trauma, surgery, or invasive procedures involving the liver or biliary tree. Symptoms of hemobilia may include abdominal pain, jaundice, and Malena (Sandbloom’s triad). Diagnosis is usually made through a liver biopsy - This statement is not entirely true . While a liver biopsy may be used to diagnose hemobilia in some cases, diagnosis is typically made through imaging tests like CECT abdomen .</li><li>• It is a rare condition where blood flows into the biliary tree - This statement is true. Hemobilia is a rare condition where bleeding occurs into the biliary tree .</li><li>• rare condition where blood flows into the biliary tree</li><li>• bleeding occurs into the biliary tree</li><li>• It is commonly caused by gallstones or inflammation of the gallbladder - This statement is not true. While gallstones or inflammation of the gallbladder can cause bleeding into the biliary tree, hemobilia is typically caused by trauma, surgery, or invasive procedures involving the liver or biliary tree.</li><li>• Symptoms of hemobilia may include abdominal pain, jaundice, and Malena (Sandbloom’s triad).</li><li>• hemobilia</li><li>• abdominal pain, jaundice, and Malena</li><li>• (Sandbloom’s triad).</li><li>• Diagnosis is usually made through a liver biopsy - This statement is not entirely true . While a liver biopsy may be used to diagnose hemobilia in some cases, diagnosis is typically made through imaging tests like CECT abdomen .</li><li>• not entirely true</li><li>• diagnosis is typically made through imaging tests like CECT abdomen</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Hemobilia is a rare condition characterized by bleeding into the biliary tract and is often associated with trauma or iatrogenic injury rather than gallstones or gallbladder inflammation . It typically presents with abdominal pain, jaundice, and melena , and the diagnosis is usually made through imaging and endoscopic procedures , not liver biopsy.</li><li>➤ Hemobilia is a rare condition</li><li>➤ bleeding into the biliary tract and is often associated with trauma or iatrogenic injury</li><li>➤ gallstones or gallbladder inflammation</li><li>➤ abdominal pain, jaundice, and melena</li><li>➤ diagnosis is usually made through imaging</li><li>➤ endoscopic procedures</li><li>➤ Ref : Bailey and Love, 28th Ed. Pg 1202.</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28th Ed. Pg 1202.</li><li>➤ Online source: https://www.sciencedirect.com/topics/medicine-and-dentistry/haemobilia</li><li>➤ Online source:</li><li>➤ https://www.sciencedirect.com/topics/medicine-and-dentistry/haemobilia</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "What is the role of Indocyanine green (ICG) dye during laparoscopic cholecystectomy?", "options": [{"label": "A", "text": "To evaluate the function of the gallbladder", "correct": false}, {"label": "B", "text": "To identify biliary anatomy and reduce the risk of injury to surrounding structures", "correct": true}, {"label": "C", "text": "To minimize bleeding during surgery by highlighting blood vessels", "correct": false}, {"label": "D", "text": "To reduce the risk of surgical site infection", "correct": false}], "correct_answer": "B. To identify biliary anatomy and reduce the risk of injury to surrounding structures", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/15/screenshot-2024-03-15-123326.jpg"], "explanation": "<p><strong>Ans. B) To identify biliary anatomy and reduce the risk of injury to surrounding structures</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: To identify biliary anatomy and reduce the risk of injury to surrounding structures . This is the primary use of ICG during laparoscopic cholecystectomy. ICG binds to plasma proteins and is excreted into the bile , providing real-time cholangiography when viewed under near-infrared light , thus enhancing the visualization of the cystic duct, common bile duct, and other biliary structures to prevent injury.</li><li>• Option B: To identify biliary anatomy and reduce the risk of injury to surrounding structures</li><li>• This is the primary use</li><li>• ICG during laparoscopic cholecystectomy.</li><li>• ICG binds to plasma proteins and is excreted into the bile</li><li>• real-time cholangiography</li><li>• under near-infrared light</li><li>• Option C: To minimize bleeding during surgery by highlighting blood vessels . ICG does help to visualize blood vessels; however, its use in laparoscopic cholecystectomy is more focused on biliary tract visualization rather than to minimize bleeding.</li><li>• Option C: To minimize bleeding during surgery by highlighting blood vessels</li><li>• ICG does help to visualize blood vessels;</li><li>• use in laparoscopic cholecystectomy</li><li>• focused on biliary tract visualization</li><li>• Option D: To reduce the risk of surgical site infection . ICG has no antimicrobial properties and does not reduce the risk of surgical site infections .</li><li>• Option D: To reduce the risk of surgical site infection</li><li>• ICG has no antimicrobial properties</li><li>• does not reduce the risk of surgical site infections</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The primary role of Indocyanine green (ICG) dye during laparoscopic cholecystectomy is to enhance the visualization of biliary anatomy , such as the cystic duct and common bile duct , in order to reduce the risk of injury to these and other surrounding structures.</li><li>➤ primary role of Indocyanine green</li><li>➤ dye</li><li>➤ laparoscopic cholecystectomy</li><li>➤ enhance the visualization of biliary anatomy</li><li>➤ cystic duct</li><li>➤ bile duct</li><li>➤ Indocyanine green (ICG) dye is used during laparoscopic cholecystectomy to help identify biliary anatomy, such as the common bile duct and cystic duct, and reduce the risk of injury to surrounding structures. ICG dye can also help to highlight blood vessels, which can aid in minimizing bleeding during surgery. However, this is not the main application in cholecystectomy. While ICG dye can be used to evaluate the function of the gallbladder and assess blood flow during surgery, this is not its primary role in laparoscopic cholecystectomy.</li><li>➤ Indocyanine green (ICG) dye is used during laparoscopic cholecystectomy to help identify biliary anatomy, such as the common bile duct and cystic duct, and reduce the risk of injury to surrounding structures.</li><li>➤ help identify biliary anatomy, such as the common bile duct and cystic duct, and</li><li>➤ reduce the risk of injury to surrounding structures.</li><li>➤ ICG dye can also help to highlight blood vessels, which can aid in minimizing bleeding during surgery. However, this is not the main application in cholecystectomy.</li><li>➤ While ICG dye can be used to evaluate the function of the gallbladder and assess blood flow during surgery, this is not its primary role in laparoscopic cholecystectomy.</li><li>➤ Ref : Bailey and Love, 28th Ed. Pg 173</li><li>➤ Ref</li><li>➤ : Bailey and Love, 28th Ed. Pg 173</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is the ideal donor for organ transplant?", "options": [{"label": "A", "text": "Brain dead donor who is an identical twin", "correct": false}, {"label": "B", "text": "Living donor who is an identical twin", "correct": true}, {"label": "C", "text": "Brain dead donor who has the same blood group", "correct": false}, {"label": "D", "text": "Living donor who has the same blood group", "correct": false}], "correct_answer": "B. Living donor who is an identical twin", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Living donor who is an identical twin</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. A brain-dead donor who is an identical twin would be an excellent match in terms of HLA compatibility . However, the organs may have suffered from the events leading to brain death and subsequent changes in physiology.</li><li>• Option A.</li><li>• excellent match</li><li>• HLA compatibility</li><li>• suffered</li><li>• events leading</li><li>• brain death</li><li>• changes in physiology.</li><li>• Option C . A brain-dead donor who has the same blood group can be a suitable donor , but without the genetic matching of an identical twin , there is a higher risk of rejection .</li><li>• Option C</li><li>• can be a suitable donor</li><li>• without</li><li>• genetic matching</li><li>• identical twin</li><li>• higher risk of rejection</li><li>• Option D . A living donor who has the same blood group is better than a deceased donor in terms of organ quality, but the risk of rejection would still be higher compared to an identical twin.</li><li>• Option D</li><li>• same blood group</li><li>• better</li><li>• deceased donor</li><li>• risk of rejection</li><li>• still be higher</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The ideal organ donor is a living donor who is an identical twin of the recipient due to the perfect HLA match and the optimal condition of the donated organ , which significantly reduces the risk of rejection and improves transplant outcomes .</li><li>➤ identical twin</li><li>➤ perfect HLA match</li><li>➤ optimal condition</li><li>➤ donated organ</li><li>➤ reduces</li><li>➤ risk of rejection</li><li>➤ improves transplant outcomes</li><li>➤ Transplants from live donors have a number of advantages over deceased donor organs . Live donor organ from healthy individuals without the comorbidities commonly seen in deceased donors . In the agonal period , before death , deceased donors exhibit marked changes in physiology related to a catecholamine storm and this can cause organ dysfunction . Clearly, live donor organs are not subjected to this insult. Allograft rejection is directed against human leukocyte antigens (HLAs) . These are a group of cell surface glycoprotein molecules. HLA molecules are divided into class I (A, B and C) and class II (DR, DP and DQ). They are highly polymorphic , i.e., their amino acid sequences differ widely between individuals . To give an example, there are &gt; 1000 variants of the HLA-B gene . This genetic variability means that most transplant donors and recipients have different HLA profiles . HLA profiles will be the same in identical twins, hence chance of mismatch is low.</li><li>➤ Transplants from live donors have a number of advantages over deceased donor organs . Live donor organ from healthy individuals without the comorbidities commonly seen in deceased donors .</li><li>➤ live donors</li><li>➤ number of advantages</li><li>➤ over deceased</li><li>➤ donor organs</li><li>➤ healthy individuals</li><li>➤ without</li><li>➤ comorbidities</li><li>➤ deceased donors</li><li>➤ In the agonal period , before death , deceased donors exhibit marked changes in physiology related to a catecholamine storm and this can cause organ dysfunction . Clearly, live donor organs are not subjected to this insult.</li><li>➤ agonal period</li><li>➤ before death</li><li>➤ deceased donors</li><li>➤ marked changes</li><li>➤ catecholamine storm</li><li>➤ organ dysfunction</li><li>➤ Allograft rejection is directed against human leukocyte antigens (HLAs) . These are a group of cell surface glycoprotein molecules. HLA molecules are divided into class I (A, B and C) and class II (DR, DP and DQ).</li><li>➤ Allograft rejection is directed against human leukocyte antigens (HLAs)</li><li>➤ class I (A, B and C) and class II (DR, DP and DQ).</li><li>➤ They are highly polymorphic , i.e., their amino acid sequences differ widely between individuals . To give an example, there are &gt; 1000 variants of the HLA-B gene . This genetic variability means that most transplant donors and recipients have different HLA profiles . HLA profiles will be the same in identical twins, hence chance of mismatch is low.</li><li>➤ highly polymorphic</li><li>➤ amino acid sequences</li><li>➤ between individuals</li><li>➤ &gt; 1000 variants</li><li>➤ HLA-B gene</li><li>➤ most transplant donors</li><li>➤ recipients</li><li>➤ different HLA profiles</li><li>➤ HLA profiles will be the same in identical twins, hence chance of mismatch is low.</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1597-99</li><li>➤ Ref : Bailey and Love, 28 th Ed. Pg 1597-99</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 55-year-old male has recently undergone a successful kidney transplant. To prevent graft rejection, his medical team plans to initiate maintenance immunosuppression therapy. Which of the following drugs is a mammalian target of rapamycin (mTOR) inhibitor that is suitable for this purpose?", "options": [{"label": "A", "text": "Sirolimus", "correct": true}, {"label": "B", "text": "Tacrolimus", "correct": false}, {"label": "C", "text": "Azathioprine", "correct": false}, {"label": "D", "text": "Mycophenolate Mofetil", "correct": false}], "correct_answer": "A. Sirolimus", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Sirolimus</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B . Tacrolimus is a calcineurin inhibitor , not an mTOR inhibitor, and is used for immunosuppression in transplant patients , but it works via a different mechanism.</li><li>• Option B</li><li>• Tacrolimus</li><li>• calcineurin inhibitor</li><li>• immunosuppression</li><li>• transplant patients</li><li>• Option C . Azathioprine is an antiproliferative agent and is used as an immunosuppressant ; however, it does not inhibit mTOR.</li><li>• Option C</li><li>• Azathioprine</li><li>• antiproliferative agent</li><li>• immunosuppressant</li><li>• Option D . Mycophenolate mofetil is also an antiproliferative agent that inhibits the proliferation of T and B cells but is not an mTOR inhibitor.</li><li>• Option D</li><li>• Mycophenolate mofetil</li><li>• antiproliferative agent</li><li>• inhibits</li><li>• proliferation of T and B cells</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Sirolimus is a mammalian target of rapamycin ( mTOR ) inhibitor used in the maintenance phase of immunosuppression following kidney transplantation to prevent graft rejection .</li><li>➤ mammalian target</li><li>➤ rapamycin</li><li>➤ mTOR</li><li>➤ inhibitor</li><li>➤ maintenance phase</li><li>➤ immunosuppression</li><li>➤ kidney transplantation</li><li>➤ prevent graft rejection</li><li>➤ Drugs used for immunosuppression in a patient for kidney transplant are:</li><li>➤ Calcineurin inhibitors</li><li>➤ Calcineurin inhibitors</li><li>➤ Calcineurin inhibitors</li><li>➤ Cyclosporine Tacrolimus</li><li>➤ Cyclosporine</li><li>➤ Tacrolimus</li><li>➤ Antiproliferative agents</li><li>➤ Antiproliferative agents</li><li>➤ Antiproliferative agents</li><li>➤ Azathioprine Mycophenolic acid</li><li>➤ Azathioprine</li><li>➤ Mycophenolic acid</li><li>➤ Mammalian target of rapamycin (mTOR) inhibitors</li><li>➤ Mammalian target of rapamycin (mTOR) inhibitors</li><li>➤ Mammalian target of rapamycin (mTOR) inhibitors</li><li>➤ Sirolimus Rapamycin Everolimus</li><li>➤ Sirolimus</li><li>➤ Rapamycin</li><li>➤ Everolimus</li><li>➤ Immunosuppression for transplantation has two phases: Induction and maintenance . Induction therapy commonly consists of a combination of high-dose intravenous steroids and the anti-CD25 monoclonal antibody basiliximab, which blocks IL-2 receptors . Other induction agents for high-risk cases are ATG and the monoclonal antibody alemtuzumab.</li><li>➤ Immunosuppression for transplantation has two phases: Induction and maintenance . Induction therapy commonly consists of a combination of high-dose intravenous steroids and the anti-CD25 monoclonal antibody basiliximab, which blocks IL-2 receptors . Other induction agents for high-risk cases are ATG and the monoclonal antibody alemtuzumab.</li><li>➤ Immunosuppression for transplantation has two phases:</li><li>➤ Induction</li><li>➤ maintenance</li><li>➤ high-dose intravenous steroids</li><li>➤ anti-CD25 monoclonal antibody basiliximab, which blocks IL-2 receptors</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1601-02</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1601-02</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the incorrect statement of the following about the technique of renal transplant?", "options": [{"label": "A", "text": "The donor kidney is transplanted heterotopically into one of the iliac fossae", "correct": false}, {"label": "B", "text": "The transplant renal vein is anastomosed end to side to the external or common iliac vein.", "correct": false}, {"label": "C", "text": "The renal artery is anastomosed end to side to the external iliac artery in a deceased donor", "correct": false}, {"label": "D", "text": "Donor ureter is anastomosed to recipient ureter via a spatulated anastomosis", "correct": true}], "correct_answer": "D. Donor ureter is anastomosed to recipient ureter via a spatulated anastomosis", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Donor ureter is anastomosed to recipient ureter via a spatulated anastomosis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. This is a correct statement as the donor kidney is typically placed in a location different from the original kidneys , which is in the retroperitoneal iliac fossa .</li><li>• Option A.</li><li>• correct statement</li><li>• donor kidney</li><li>• original kidneys</li><li>• retroperitoneal iliac fossa</li><li>• Option B . This is the standard practice for the venous anastomosis in renal transplantation , making this statement correct .</li><li>• Option B</li><li>• standard practice</li><li>• venous anastomosis</li><li>• renal transplantation</li><li>• correct</li><li>• Option C . This is also correct as the renal artery can be anastomosed to the external iliac artery via a “Carrel patch” which can be obtained in deceased donor . In living donor transplants, the donor renal artery is anastomosed to recipient internal iliac artery .</li><li>• Option C</li><li>• also correct</li><li>• renal artery</li><li>• anastomosed</li><li>• external iliac artery</li><li>• “Carrel patch”</li><li>• obtained</li><li>• deceased donor</li><li>• donor renal artery</li><li>• anastomosed</li><li>• recipient internal iliac artery</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In renal transplantation , the donor ureter is not anastomosed to the recipient ureter but is instead anastomosed to the bladder as an extra-vesical anastomosis using the Lich–Grégoir technique .</li><li>➤ renal transplantation</li><li>➤ instead anastomosed</li><li>➤ bladder</li><li>➤ extra-vesical anastomosis</li><li>➤ Lich–Grégoir technique</li><li>➤ Renal transplant operative technique</li><li>➤ Renal transplant operative technique</li><li>➤ The donor kidney is transplanted heterotopically into one of the iliac fossa via a curvilinear incision. The transplant renal vein is anastomosed end to side to the external or common iliac vein. The renal artery is anastomosed either end to side to the external or common iliac artery (via Carrels aortic patch) or end to end to the divided internal iliac artery The internal iliac artery is used more commonly for live donor kidneys because of the lack of an aortic patch. After revascularisation of the transplant kidney the ureter is anastomosed to the bladder as an extra-vesical only (the Lich–Grégoir technique)</li><li>➤ The donor kidney is transplanted heterotopically into one of the iliac fossa via a curvilinear incision.</li><li>➤ heterotopically into one of the iliac fossa</li><li>➤ The transplant renal vein is anastomosed end to side to the external or common iliac vein.</li><li>➤ renal vein is anastomosed end to side</li><li>➤ The renal artery is anastomosed either end to side to the external or common iliac artery (via Carrels aortic patch) or end to end to the divided internal iliac artery</li><li>➤ renal artery is anastomosed either end to side</li><li>➤ The internal iliac artery is used more commonly for live donor kidneys because of the lack of an aortic patch.</li><li>➤ After revascularisation of the transplant kidney the ureter is anastomosed to the bladder as an extra-vesical only (the Lich–Grégoir technique)</li><li>➤ ureter is anastomosed to the bladder as an extra-vesical only</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1604</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1604</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Transplantation of a pair of marginal quality kidneys from the same donor into one recipient in order to provide adequate nephron mass is called as?", "options": [{"label": "A", "text": "Sub-Optimal Kidney Transplant", "correct": false}, {"label": "B", "text": "Dual Kidney Transplant", "correct": true}, {"label": "C", "text": "Additional Kidney Transplant", "correct": false}, {"label": "D", "text": "Domino Kidney Transplant", "correct": false}], "correct_answer": "B. Dual Kidney Transplant", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Dual Kidney Transplant</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Sub-optimal kidney transplant typically refers to a transplant involving a kidney that is not in optimal condition, but can be used a bridge to formal renal transplant .</li><li>• Option A.</li><li>• transplant</li><li>• kidney</li><li>• bridge</li><li>• formal renal transplant</li><li>• Option C . Additional kidney transplant is not a standard term used in transplant medicine for this scenario.</li><li>• Option C</li><li>• Option D . Domino kidney transplant refers to a specific type of transplant where an organ or tissue is transplanted from one person to another and then from that person to another recipient , which is not the case described.</li><li>• Option D</li><li>• specific type of transplant</li><li>• organ or tissue</li><li>• transplanted</li><li>• one person</li><li>• another</li><li>• person</li><li>• another recipient</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Dual kidney transplantation is the process where two marginal quality kidneys from the same donor are transplanted into one recipient to ensure adequate nephron mass and function .</li><li>➤ two marginal quality kidneys</li><li>➤ same donor</li><li>➤ transplanted</li><li>➤ one recipient</li><li>➤ adequate nephron mass</li><li>➤ function</li><li>➤ Dual kidney transplantation</li><li>➤ Dual kidney transplantation</li><li>➤ This involves the transplantation of a pair of marginal quality kidneys from the same donor into one recipient in order to provide adequate nephron mass. Both kidneys can be placed in the same iliac fossa . This approach is used for kidneys from elderly Donor after Circulatory Death and so-called expanded criteria donors, which are defined by age &gt; 60 years or age &gt;50 years with at least two of the following: hypertension; terminal creatinine &gt;133 μmol/L; death from stroke.</li><li>➤ This involves the transplantation of a pair of marginal quality kidneys from the same donor into one recipient in order to provide adequate nephron mass.</li><li>➤ Both kidneys can be placed in the same iliac fossa .</li><li>➤ Both kidneys can be placed in the same iliac fossa</li><li>➤ This approach is used for kidneys from elderly Donor after Circulatory Death and so-called expanded criteria donors, which are defined by age &gt; 60 years or age &gt;50 years with at least two of the following: hypertension; terminal creatinine &gt;133 μmol/L; death from stroke.</li><li>➤ expanded criteria donors, which are defined by age &gt; 60 years or age &gt;50 years with at least two of the following:</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1604</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1604</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is not a cause of early graft dysfunction in renal transplant patient?", "options": [{"label": "A", "text": "Recurrence of Disease", "correct": true}, {"label": "B", "text": "Renal Vein Thrombosis", "correct": false}, {"label": "C", "text": "Renal Artery Stenosis", "correct": false}, {"label": "D", "text": "Dehydration", "correct": false}], "correct_answer": "A. Recurrence of Disease", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Recurrence of Disease</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B : Renal vein thrombosis is a significant cause of early graft dysfunction due to the immediate impairment of blood flow it can cause in the transplanted kidney .</li><li>• Option B</li><li>• significant cause</li><li>• early graft dysfunction</li><li>• immediate impairment</li><li>• blood flow</li><li>• transplanted kidney</li><li>• Option C : Renal artery stenosis can lead to early graft dysfunction by reducing blood flow to the transplanted kidney , causing ischemia and potentially acute renal failure .</li><li>• Option C</li><li>• early graft dysfunction</li><li>• reducing blood flow</li><li>• transplanted kidney</li><li>• ischemia</li><li>• potentially acute renal failure</li><li>• Option D : Dehydration can cause pre-renal acute kidney injury by decreasing blood flow to the kidneys , leading to early graft dysfunction if severe .</li><li>• Option D</li><li>• pre-renal acute kidney injury</li><li>• decreasing blood flow</li><li>• kidneys</li><li>• early graft dysfunction</li><li>• severe</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Recurrence of the original disease is not a common cause of early graft dysfunction in renal transplant patients; as such recurrences typically occur later in the post-transplant course . Early graft dysfunction is more often caused by factors such as acute rejection, vascular complications, infections, or technical issues .</li><li>➤ later</li><li>➤ post-transplant course</li><li>➤ Early graft dysfunction</li><li>➤ acute rejection, vascular complications, infections, or technical issues</li><li>➤ Causes of early graft dysfunction</li><li>➤ Causes of early graft dysfunction</li><li>➤ Any rise in serum creatinine of &gt;10% of baseline or ≥20 μmol/L should be considered as acute allograft dysfunction that requires investigation . Possible causes are:</li><li>➤ Any rise</li><li>➤ serum creatinine</li><li>➤ &gt;10% of baseline</li><li>➤ ≥20 μmol/L</li><li>➤ acute allograft dysfunction</li><li>➤ requires investigation</li><li>➤ Acute Rejection (Antibody Mediated or Cell Mediated) Calcineurin Inhibitor Toxicity Dehydration Urinary Tract Infection or Pyelonephritis Any other source of Sepsis Renal Vein or Renal Artery Thrombosis Ureteric Obstruction or Urine Leak</li><li>➤ Acute Rejection (Antibody Mediated or Cell Mediated)</li><li>➤ Calcineurin Inhibitor Toxicity</li><li>➤ Dehydration</li><li>➤ Urinary Tract Infection or Pyelonephritis</li><li>➤ Any other source of Sepsis</li><li>➤ Renal Vein or Renal Artery Thrombosis</li><li>➤ Ureteric Obstruction or Urine Leak</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1606</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1606</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 58-year-old male who underwent a kidney transplant 7 years ago presents with gradually worsening renal function over the past year. He has no signs of infection, maintains good hydration, and reports compliance with his immunosuppressive medications. A renal biopsy reveals interstitial fibrosis and tubular atrophy without evidence of acute inflammatory changes. Which of the following is the most likely cause of this patient's renal dysfunction?", "options": [{"label": "A", "text": "Acute Rejection", "correct": false}, {"label": "B", "text": "Chronic Rejection", "correct": true}, {"label": "C", "text": "Renal Artery Stenosis", "correct": false}, {"label": "D", "text": "Dehydration", "correct": false}], "correct_answer": "B. Chronic Rejection", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Chronic Rejection</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Acute rejection, both antibody-mediated (AMR) and cell-mediated (CMR) , can lead to early graft dysfunction (within few months).</li><li>• Option A.</li><li>• both antibody-mediated (AMR)</li><li>• cell-mediated (CMR)</li><li>• early graft dysfunction</li><li>• Option C . Renal artery stenosis can lead to graft dysfunction due to ischemia ; however, it is less common than chronic rejection and doesn’t match the biopsy.</li><li>• Option C</li><li>• ischemia</li><li>• Option D . Dehydration can cause acute pre-renal failure but is not a common cause of long-term graft failure in kidney transplant patients.</li><li>• Option D</li><li>• acute pre-renal failure</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Chronic rejection is the most common cause of graft failure/dysfunction in kidney transplant , typically presenting as progressive organ dysfunction over time due to immunological factors .</li><li>➤ most common cause</li><li>➤ graft failure/dysfunction</li><li>➤ kidney transplant</li><li>➤ progressive organ dysfunction</li><li>➤ immunological factors</li><li>➤ Causes of long-term graft dysfunction</li><li>➤ Causes of long-term graft dysfunction</li><li>➤ Immunological</li><li>➤ Immunological</li><li>➤ Chronic AMR (anti-body mediated rejection) Acute CMR (cell mediated rejection) or AMR, which can occur at any time</li><li>➤ Chronic AMR (anti-body mediated rejection)</li><li>➤ Acute CMR (cell mediated rejection) or AMR, which can occur at any time</li><li>➤ Non-immunological :</li><li>➤ Non-immunological</li><li>➤ Pre-existing damage in the donor kidney (especially relevant to DCD and extended criteria donor kidneys) Early ischaemia - Reperfusion injury Chronic calcineurin nephrotoxicity Ureteric or bladder outflow obstruction Recurrent urinary tract infection or pyelonephritis BK polyomavirus nephropathy Recurrent native disease: glomerulonephritis; focal segmental glomerulosclerosis; immunoglobulin A nephropathy Renal artery stenosis Poorly controlled hypertension Dyslipidaemia</li><li>➤ Pre-existing damage in the donor kidney (especially relevant to DCD and extended criteria donor kidneys)</li><li>➤ Early ischaemia - Reperfusion injury</li><li>➤ Early ischaemia - Reperfusion injury</li><li>➤ Chronic calcineurin nephrotoxicity</li><li>➤ Ureteric or bladder outflow obstruction</li><li>➤ Recurrent urinary tract infection or pyelonephritis</li><li>➤ BK polyomavirus nephropathy</li><li>➤ Recurrent native disease: glomerulonephritis; focal segmental glomerulosclerosis; immunoglobulin A nephropathy</li><li>➤ Recurrent native disease: glomerulonephritis; focal segmental glomerulosclerosis; immunoglobulin A nephropathy</li><li>➤ Renal artery stenosis</li><li>➤ Poorly controlled hypertension</li><li>➤ Dyslipidaemia</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1606-1607</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1606-1607</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 63-year-old male, who received a kidney transplant 2 years ago and has been on chronic immunosuppressive therapy, presents with multiple hyperkeratotic lesions on sun-exposed areas of the skin. Biopsy of one lesion confirms malignancy. Which of the following is the most likely diagnosis?", "options": [{"label": "A", "text": "Post-Transplant Lymphoproliferative Disorder (PTLD)", "correct": false}, {"label": "B", "text": "Squamous Cell Carcinoma of the Skin", "correct": true}, {"label": "C", "text": "Leukemia", "correct": false}, {"label": "D", "text": "Kaposi’s Sarcoma", "correct": false}], "correct_answer": "B. Squamous Cell Carcinoma of the Skin", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Squamous Cell Carcinoma of the Skin</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A . PTLD refers to a range of lymphoid proliferations that can occur following transplantation due to immunosuppression . However, it does not present with hyperkeratotic skin lesions.</li><li>• Option A</li><li>• range</li><li>• lymphoid proliferations</li><li>• transplantation</li><li>• immunosuppression</li><li>• Option C . Leukemia can occur in the post-transplant setting but would not present with localized skin lesions, but with pancytopenia and splenomegaly.</li><li>• Option C</li><li>• post-transplant setting</li><li>• Option D . Kaposi’s sarcoma can occur in transplant patients but typically presents as violaceous plaques or nodules and is less common than squamous cell carcinoma in these patients.</li><li>• Option D</li><li>• transplant patients</li><li>• typically presents</li><li>• violaceous plaques</li><li>• nodules</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most common malignancy seen post-transplant in patients on immunosuppressive therapy is squamous cell carcinoma of the skin , often occurring on sun-exposed areas .</li><li>➤ most common malignancy</li><li>➤ post-transplant</li><li>➤ immunosuppressive therapy</li><li>➤ squamous cell carcinoma</li><li>➤ skin</li><li>➤ sun-exposed areas</li><li>➤ Most common malignancy seen post-transplant immunosuppressive therapy is Squamous cell carcinoma of skin</li><li>➤ Squamous cell carcinoma</li><li>➤ Complications of immunosuppression:</li><li>➤ Complications of immunosuppression:</li><li>➤ Infections:</li><li>➤ Infections:</li><li>➤ 1. CMV - 4 to 8 weeks Post-Transplant - Pneumonia/Retinitis/Encephalitis</li><li>➤ 1. CMV</li><li>➤ Treatment - Valganciclovir</li><li>➤ 2. Pneumocystis jirovecii - Fungal Pneumonia</li><li>➤ 2. Pneumocystis jirovecii</li><li>➤ Malignancy: - Skin Cancers (MC- Squamous Cell Carcinoma)</li><li>➤ Malignancy: -</li><li>➤ Ref: Bailey and Love 27 th Ed. Pg 1541, Box 82.5</li><li>➤ Ref: Bailey and Love 27 th Ed. Pg 1541, Box 82.5</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Maastricht grading is used to categorize?", "options": [{"label": "A", "text": "Living Related Donor", "correct": false}, {"label": "B", "text": "Living Unrelated Donor", "correct": false}, {"label": "C", "text": "Deceased Brain-Dead Donor", "correct": false}, {"label": "D", "text": "Deceased Circulatory Dead Donor", "correct": true}], "correct_answer": "D. Deceased Circulatory Dead Donor", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/30/picture1_Cev8cvf.jpg"], "explanation": "<p><strong>Ans. D) Deceased Circulatory Dead Donor</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 46-year-old male with a history of a brain lesion treated with surgical resection and no evidence of metastasis is evaluated for kidney transplantation. Which of the following conditions in the patient's history is not considered an absolute contraindication to transplant?", "options": [{"label": "A", "text": "Severe Acute Pancreatitis with Sepsis", "correct": false}, {"label": "B", "text": "Malignant Melanoma", "correct": false}, {"label": "C", "text": "Prion Disease", "correct": false}, {"label": "D", "text": "Primary CNS Tumor", "correct": true}], "correct_answer": "D. Primary CNS Tumor", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Primary CNS Tumor</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Severe acute pancreatitis with sepsis is typically a contraindication , until the sepsis is under control . Active systemic sepsis at the time of transplant would be an absolute contraindication .</li><li>• Option A.</li><li>• contraindication</li><li>• sepsis</li><li>• under control</li><li>• Active systemic sepsis</li><li>• time of transplant</li><li>• absolute contraindication</li><li>• Option B . Melanoma is an absolute contraindication to transplant . Non-melanotic skin tumors are not.</li><li>• Option B</li><li>• absolute contraindication</li><li>• transplant</li><li>• Option C. Prion disease , such as Creutzfeldt-Jakob disease , is an absolute contraindication to organ transplantation due to the high risk of transmitting the disease through transplanted tissues .</li><li>• Option C.</li><li>• Prion disease</li><li>• Creutzfeldt-Jakob disease</li><li>• absolute contraindication</li><li>• organ transplantation</li><li>• high risk</li><li>• transmitting</li><li>• disease</li><li>• transplanted tissues</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Primary CNS tumors, particularly those that are localized and have been treated without evidence of metastasis, are not considered an absolute contraindication to organ transplantation. This is in contrast to systemic malignancies and certain untreatable or high-risk infections.</li><li>➤ localized</li><li>➤ Contraindication to organ transplant:</li><li>➤ Contraindication to organ transplant:</li><li>➤ Absolute</li><li>➤ Absolute</li><li>➤ Creutzfeldt Jacobson Disease (Prion Disease) Active Systemic Sepsis Malignancy in previous 5 years (except Primary CNS tumour, Non-Melanotic Skin Ca and CIS of uterus)</li><li>➤ Creutzfeldt Jacobson Disease (Prion Disease)</li><li>➤ Active Systemic Sepsis</li><li>➤ Malignancy in previous 5 years (except Primary CNS tumour, Non-Melanotic Skin Ca and CIS of uterus)</li><li>➤ Relative</li><li>➤ Relative</li><li>➤ As a further response to the organ donor shortage , organs are now being transplanted from donors with meningitis/encephalitis , human immunodeficiency virus (HIV) , hepatitis B and C and high-risk behaviour with the potential for blood-borne infection</li><li>➤ As a further response to the organ donor shortage , organs are now being transplanted from donors with meningitis/encephalitis , human immunodeficiency virus (HIV) , hepatitis B and C and high-risk behaviour with the potential for blood-borne infection</li><li>➤ organ donor shortage</li><li>➤ transplanted from donors</li><li>➤ meningitis/encephalitis</li><li>➤ human immunodeficiency virus (HIV)</li><li>➤ hepatitis B</li><li>➤ C</li><li>➤ high-risk behaviour</li><li>➤ potential</li><li>➤ blood-borne infection</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1596-97</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1596-97</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 25-year-old type 1 diabetic with ESRD underwent simultaneous pancreatic-kidney transplant (SPK). Which of these is not a complication of bladder drainage of transplanted pancreas?", "options": [{"label": "A", "text": "Metabolic Alkalosis", "correct": true}, {"label": "B", "text": "Chemical Cystitis", "correct": false}, {"label": "C", "text": "Reflux Pancreatitis", "correct": false}, {"label": "D", "text": "Prostatic Abscess", "correct": false}], "correct_answer": "A. Metabolic Alkalosis", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/30/picture2.jpg"], "explanation": "<p><strong>Ans. A) Metabolic Alkalosis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• If transplanted pancreas is drained into bladder instead of small bowel , there is loss of bicarbonates from the pancreatic secretions , leading to metabolic acidosis .</li><li>• transplanted pancreas</li><li>• drained</li><li>• bladder</li><li>• small bowel</li><li>• loss of bicarbonates</li><li>• pancreatic secretions</li><li>• metabolic acidosis</li><li>• Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1627</li><li>• Ref</li><li>• : Bailey and Love’s short practice of surgery 28 th edition pg 1627</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 55-year-old patient with Child C Cirrhosis and Hepatitis C is undergoing a liver transplant. Which anatomical structure should the surgeon prepare to anastomose first in the recipient?", "options": [{"label": "A", "text": "Hepatic Artery", "correct": false}, {"label": "B", "text": "Portal Vein", "correct": false}, {"label": "C", "text": "Bile Duct", "correct": false}, {"label": "D", "text": "IVC", "correct": true}], "correct_answer": "D. IVC", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D. IVC</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option D : The IVC, both supra-hepatic and infra-hepatic , is usually the first part to be anastomosed during liver transplantation to establish venous outflow from the liver , which is critical to providing immediate blood drainage from the graft .</li><li>• Option D</li><li>• both supra-hepatic</li><li>• infra-hepatic</li><li>• first part</li><li>• anastomosed</li><li>• liver transplantation</li><li>• establish venous outflow</li><li>• liver</li><li>• critical</li><li>• providing immediate blood drainage</li><li>• graft</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ The first structure to be anastomosed in the recipient of a liver transplant is the IVC , specifically starting with the supra-hepatic IVC , followed by the infra-hepatic IVC , to establish adequate venous outflow from the liver .</li><li>➤ first structure</li><li>➤ anastomosed</li><li>➤ recipient</li><li>➤ liver transplant</li><li>➤ IVC</li><li>➤ starting</li><li>➤ supra-hepatic IVC</li><li>➤ infra-hepatic IVC</li><li>➤ establish adequate venous outflow</li><li>➤ liver</li><li>➤ Order of anastomosis in recipient of liver transplant is:</li><li>➤ anastomosis</li><li>➤ recipient</li><li>➤ liver transplant</li><li>➤ Supra-hepatic IVC Infra-hepatic IVC Portal Vein Hepatic Artery Bile duct</li><li>➤ Supra-hepatic IVC</li><li>➤ Infra-hepatic IVC</li><li>➤ Portal Vein</li><li>➤ Hepatic Artery</li><li>➤ Bile duct</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1610-1611</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1610-1611</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In a patient with graft-versus-host disease (GVHD) following a hematopoietic stem cell transplant, which organ is least likely to affect by this condition?", "options": [{"label": "A", "text": "Skin", "correct": false}, {"label": "B", "text": "Gastrointestinal tract", "correct": false}, {"label": "C", "text": "Liver", "correct": false}, {"label": "D", "text": "Lung", "correct": true}], "correct_answer": "D. Lung", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Lung</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A . The skin is commonly affected in GVHD, presenting with rashes and can progress to desquamation .</li><li>• Option A</li><li>• commonly affected</li><li>• rashes</li><li>• desquamation</li><li>• Option B. The gastrointestinal tract is frequently involved in GVHD, which can manifest as diarrhea, abdominal pain , and gastrointestinal bleeding .</li><li>• Option B.</li><li>• frequently involved</li><li>• manifest</li><li>• diarrhea, abdominal pain</li><li>• gastrointestinal bleeding</li><li>• Option C. The liver can be affected in GVHD, leading to elevated liver enzymes , jaundice , and cholestasis .</li><li>• Option C.</li><li>• affected</li><li>• elevated liver enzymes</li><li>• jaundice</li><li>• cholestasis</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• While any organ can be affected by graft-versus-host disease , the lung is typically the least affected organ compared to the skin, liver , and gastrointestinal tract , which are more commonly involved in acute presentations of the disease .</li><li>• affected</li><li>• graft-versus-host disease</li><li>• least affected organ</li><li>• skin, liver</li><li>• gastrointestinal tract</li><li>• commonly</li><li>• acute presentations</li><li>• disease</li><li>• Graft-versus-host disease (GVHD) occurs due to the presence of immunocompetent T lymphocytes in the graft attacking the immunodeficient recipient tissue due to histocompatibility differences within 100 days , causing tissue damage. Organ most affected by GVHD - Skin Organ least affected by GVHD - Lung Any organ can be affected in GVH reaction. The most important is the involvement of immune system, skin, liver and intestines.</li><li>• Graft-versus-host disease (GVHD) occurs due to the presence of immunocompetent T lymphocytes in the graft attacking the immunodeficient recipient tissue due to histocompatibility differences within 100 days , causing tissue damage.</li><li>• the presence of immunocompetent T lymphocytes in the graft attacking the immunodeficient recipient tissue due to histocompatibility differences within 100 days</li><li>• Organ most affected by GVHD - Skin</li><li>• Skin</li><li>• Organ least affected by GVHD - Lung</li><li>• Lung</li><li>• Any organ can be affected in GVH reaction. The most important is the involvement of immune system, skin, liver and intestines.</li><li>• Ref : Online reference – Bailey and Love 27 th Ed. Pg 1537 .</li><li>• Ref : Online reference –</li><li>• Bailey and Love 27 th Ed. Pg 1537</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is incorrect about liver transplant?", "options": [{"label": "A", "text": "Most common indication in a child is biliary atresia", "correct": false}, {"label": "B", "text": "Liver transplant may be done in liver malignancies", "correct": false}, {"label": "C", "text": "In auxiliary liver transplant, native liver is left in situ", "correct": false}, {"label": "D", "text": "Liver is resistant to acute rejection", "correct": true}], "correct_answer": "D. Liver is resistant to acute rejection", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Biliary atresia is indeed the most common indication for liver transplantation in children , making this statement correct.</li><li>• Option A.</li><li>• Biliary atresia</li><li>• most common indication</li><li>• liver transplantation</li><li>• children</li><li>• Option B . Liver transplantation is an established treatment for selected patients with Hepato-Cellular Carcinoma (HCC) and fulfills specific criteria such as the Milan or UCSF criteria .</li><li>• Option B</li><li>• established</li><li>• selected patients</li><li>• Hepato-Cellular Carcinoma</li><li>• fulfills</li><li>• Milan</li><li>• UCSF criteria</li><li>• Option C. In auxiliary liver transplantation, part of the native liver is left in place, and a portion of a donor liver is implanted . This procedure may be considered for certain indications, making this statement correct.</li><li>• Option C.</li><li>• donor liver</li><li>• implanted</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• The liver is not resistant to acute rejection ; it is susceptible to acute rejection like any other transplanted organ, and acute cellular rejection is a common cause of graft dysfunction early after liver transplantation .</li><li>• not resistant</li><li>• acute rejection</li><li>• susceptible</li><li>• acute rejection</li><li>• acute cellular rejection</li><li>• common cause</li><li>• graft dysfunction</li><li>• after liver transplantation</li><li>• In adults the most common causes are alcoholic liver disease, non-alcoholic fatty liver disease (NAFLD), chronic viral hepatitis (hepatitis B virus [HBV] and hepatitis C virus [HCV]) . In the last two decades hepatitis-related CLD (HBV and HCV) was the most common indication for LT. In children, who account for around 10–15% of all LTs, biliary atresia is the most common indication for transplantation. LTx is indicated as a curative treatment for selected patients with HCC , haemangioendothelioma and hepatoblastoma. Milan criteria (one lesion ≤5 cm, or three or fewer lesions ≤3 cm each) UCSF criteria (one lesion ≤6.5 cm, or three or fewer lesions ≤4.5 cm each, with a total tumour diameter ≤8 cm) Auxiliary LT involves implanting a healthy liver graft placed either heterotopically or orthotopically while leaving all or part of the native liver intact. Auxiliary heterotopic LT, where the graft is implanted below the native liver, was proposed as an alternative to orthotopic LT. Liver graft dysfunction can happen any time after transplantation; if not identified early and treated promptly, it can lead to graft loss. The most common presentation is an asymptomatic elevation of liver enzyme levels . Early after LT, acute cellular rejection is the most common cause of graft dysfunction and is usually treated by increasing the dose of immunosuppression.</li><li>• In adults the most common causes are alcoholic liver disease, non-alcoholic fatty liver disease (NAFLD), chronic viral hepatitis (hepatitis B virus [HBV] and hepatitis C virus [HCV]) . In the last two decades hepatitis-related CLD (HBV and HCV) was the most common indication for LT.</li><li>• most common causes are alcoholic liver disease, non-alcoholic fatty liver disease (NAFLD), chronic viral hepatitis (hepatitis B virus [HBV] and hepatitis C virus [HCV])</li><li>• In children, who account for around 10–15% of all LTs, biliary atresia is the most common indication for transplantation.</li><li>• biliary atresia is the most common indication for transplantation.</li><li>• LTx is indicated as a curative treatment for selected patients with HCC , haemangioendothelioma and hepatoblastoma.</li><li>• curative treatment</li><li>• selected patients</li><li>• HCC</li><li>• haemangioendothelioma</li><li>• hepatoblastoma.</li><li>• Milan criteria (one lesion ≤5 cm, or three or fewer lesions ≤3 cm each)</li><li>• Milan criteria</li><li>• UCSF criteria (one lesion ≤6.5 cm, or three or fewer lesions ≤4.5 cm each, with a total tumour diameter ≤8 cm)</li><li>• UCSF criteria</li><li>• Auxiliary LT involves implanting a healthy liver graft placed either heterotopically or orthotopically while leaving all or part of the native liver intact. Auxiliary heterotopic LT, where the graft is implanted below the native liver, was proposed as an alternative to orthotopic LT.</li><li>• Auxiliary LT involves implanting a healthy liver graft placed either heterotopically or orthotopically while leaving all or part of the native liver intact.</li><li>• Liver graft dysfunction can happen any time after transplantation; if not identified early and treated promptly, it can lead to graft loss. The most common presentation is an asymptomatic elevation of liver enzyme levels . Early after LT, acute cellular rejection is the most common cause of graft dysfunction and is usually treated by increasing the dose of immunosuppression.</li><li>• The most common presentation is an asymptomatic elevation of liver enzyme levels</li><li>• acute cellular rejection is the most common cause</li><li>• Ref : Bailey 28 th Ed. Pg 1608, 1610, 1614, 1618.</li><li>• Ref : Bailey 28 th Ed. Pg 1608, 1610, 1614, 1618.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the incorrect statement about graft rejection:", "options": [{"label": "A", "text": "Hyperacute Rejection occurs due to T Cell Mediated Destruction", "correct": true}, {"label": "B", "text": "Acute Rejection occurs during first 6 Months", "correct": false}, {"label": "C", "text": "Chronic Rejection is the most common cause of Graft Failure", "correct": false}, {"label": "D", "text": "Chronic Rejection is characterized by Myo-Intimal Proliferation on Biopsy", "correct": false}], "correct_answer": "A. Hyperacute Rejection occurs due to T Cell Mediated Destruction", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Hyperacute Rejection occurs due to T Cell Mediated Destruction</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B.</li><li>• Option B.</li><li>• This statement is generally accurate . Acute rejection is most common in the early post-transplant period , and it often occurs within the first few months after transplantation . However, acute rejection can occur at any time post-transplant .</li><li>• This statement is generally accurate . Acute rejection is most common in the early post-transplant period , and it often occurs within the first few months after transplantation . However, acute rejection can occur at any time post-transplant .</li><li>• accurate</li><li>• early post-transplant period</li><li>• first few months</li><li>• transplantation</li><li>• any time post-transplant</li><li>• Option C.</li><li>• Option C.</li><li>• This statement is correct . Chronic rejection can contribute to graft failure over time. Graft failure can result from various factors, including acute rejection , infections , vascular complications , and other non-immunological factors.</li><li>• This statement is correct . Chronic rejection can contribute to graft failure over time. Graft failure can result from various factors, including acute rejection , infections , vascular complications , and other non-immunological factors.</li><li>• correct</li><li>• graft failure</li><li>• Graft failure</li><li>• acute rejection</li><li>• infections</li><li>• vascular complications</li><li>• Option D.</li><li>• Option D.</li><li>• This statement is generally accurate . Chronic rejection is associated with long-term changes , including fibrosis and myo-intimal proliferation in the blood vessels of the transplanted organ . This can be observed on biopsy as a characteristic feature of chronic rejection .</li><li>• This statement is generally accurate . Chronic rejection is associated with long-term changes , including fibrosis and myo-intimal proliferation in the blood vessels of the transplanted organ . This can be observed on biopsy as a characteristic feature of chronic rejection .</li><li>• generally accurate</li><li>• Chronic rejection</li><li>• long-term changes</li><li>• fibrosis</li><li>• myo-intimal proliferation</li><li>• blood vessels</li><li>• transplanted organ</li><li>• biopsy</li><li>• chronic rejection</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Types of Graft Rejection</li><li>➤ Types of Graft Rejection</li><li>➤ Hyperacute rejection Immediate graft destruction due to ABO or preformed anti-HLA antibodies Characterised by intravascular thrombosis and interstitial haemorrhage Acute rejection Usually occurs during first 6 months T-cell dependent May be cell mediated, antibody mediated or both Usually reversible Chronic rejection Occurs after first 6 months Most common cause of graft failure Antibodies play an important role Noe-immune factors contribute to pathogenesis Characterised by myointimal proliferation in graft arteries leading to ischaemia and fibrosis</li><li>➤ Hyperacute rejection Immediate graft destruction due to ABO or preformed anti-HLA antibodies Characterised by intravascular thrombosis and interstitial haemorrhage</li><li>➤ Hyperacute rejection</li><li>➤ Immediate graft destruction due to ABO or preformed anti-HLA antibodies Characterised by intravascular thrombosis and interstitial haemorrhage</li><li>➤ Immediate graft destruction due to ABO or preformed anti-HLA antibodies</li><li>➤ Characterised by intravascular thrombosis and interstitial haemorrhage</li><li>➤ Acute rejection Usually occurs during first 6 months T-cell dependent May be cell mediated, antibody mediated or both Usually reversible</li><li>➤ Acute rejection</li><li>➤ Usually occurs during first 6 months T-cell dependent May be cell mediated, antibody mediated or both Usually reversible</li><li>➤ Usually occurs during first 6 months</li><li>➤ T-cell dependent</li><li>➤ May be cell mediated, antibody mediated or both</li><li>➤ Usually reversible</li><li>➤ Chronic rejection Occurs after first 6 months Most common cause of graft failure Antibodies play an important role Noe-immune factors contribute to pathogenesis Characterised by myointimal proliferation in graft arteries leading to ischaemia and fibrosis</li><li>➤ Chronic rejection</li><li>➤ Occurs after first 6 months Most common cause of graft failure Antibodies play an important role Noe-immune factors contribute to pathogenesis Characterised by myointimal proliferation in graft arteries leading to ischaemia and fibrosis</li><li>➤ Occurs after first 6 months</li><li>➤ Most common cause of graft failure</li><li>➤ Antibodies play an important role</li><li>➤ Noe-immune factors contribute to pathogenesis</li><li>➤ Characterised by myointimal proliferation in graft arteries leading to ischaemia and fibrosis</li><li>➤ Ref : Bailey 27 th Ed. PG 1535.</li><li>➤ Ref : Bailey 27 th Ed. PG 1535.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}]; if (!Array.isArray(questions) || questions.length === 0) { throw new Error("Questions data is empty or invalid"); } debugLog(`Successfully parsed ${questions.length} questions`); } catch (e) { console.error("Failed to parse questions_json:", e); document.getElementById('error-message').innerHTML = "Error loading quiz data. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('start-test').disabled = true; // Fallback to sample questions for testing questions = [ { text: "What is 2 + 2?", options: [ { label: "A", text: "3", correct: false }, { label: "B", text: "4", correct: true }, { label: "C", text: "5", correct: false }, { label: "D", text: "6", correct: false } ], correct_answer: "B. 4", question_images: [], explanation_images: [], explanation: "<p>2 + 2 = 4</p><p>@dams_new_robot</p>", bot: "@dams_new_robot", audio: "", video: "" } ]; debugLog("Loaded fallback questions"); } // Quiz state let currentQuestion = 0; let answers = new Array(questions.length).fill(null); let markedForReview = new Array(questions.length).fill(false); let timeRemaining = 61 * 60; // Duration in seconds let timerInterval = null; const quizId = `{title.replace(/\s+/g, '_').toLowerCase()}`; // Unique ID for local storage // Load saved progress function loadProgress() { try { debugLog("Loading progress from localStorage"); const saved = localStorage.getItem(`quiz_${quizId}`); if (saved) { const { savedAnswers, savedMarked, savedTime } = JSON.parse(saved); answers = savedAnswers || answers; markedForReview = savedMarked || markedForReview; timeRemaining = savedTime !== undefined ? savedTime : timeRemaining; debugLog("Progress loaded successfully"); } else { debugLog("No saved progress found"); } } catch (e) { console.error("Error loading progress:", e); debugLog("Failed to load progress: " + e.message); } } // Save progress function saveProgress() { try { debugLog("Saving progress to localStorage"); localStorage.setItem(`quiz_${quizId}`, JSON.stringify({ savedAnswers: answers, savedMarked: markedForReview, savedTime: timeRemaining })); debugLog("Progress saved successfully"); } catch (e) { console.error("Error saving progress:", e); debugLog("Failed to save progress: " + e.message); } } // Initialize quiz function initQuiz() { try { debugLog("Initializing quiz"); loadProgress(); const startButton = document.getElementById('start-test'); if (!startButton) { throw new Error("Start test button not found"); } startButton.addEventListener('click', startQuiz); debugLog("Start test button listener attached"); document.getElementById('previous-btn').addEventListener('click', showPreviousQuestion); document.getElementById('next-btn').addEventListener('click', showNextQuestion); document.getElementById('mark-review').addEventListener('click', toggleMarkForReview); document.getElementById('nav-toggle').addEventListener('click', toggleNavPanel); document.getElementById('submit-test').addEventListener('click', showSubmitModal); document.getElementById('continue-test').addEventListener('click', closeExitModal); document.getElementById('exit-test').addEventListener('click', () => { debugLog("Exiting test"); localStorage.removeItem(`quiz_${quizId}`); window.location.reload(); }); document.getElementById('cancel-submit').addEventListener('click', closeSubmitModal); document.getElementById('confirm-submit').addEventListener('click', submitTest); document.getElementById('take-again').addEventListener('click', () => { debugLog("Restarting test"); localStorage.removeItem(`quiz_${quizId}`); window.location.reload(); }); document.getElementById('review-test').addEventListener('click', () => showResults(currentResultQuestion)); document.getElementById('close-nav').addEventListener('click', toggleNavPanel); document.getElementById('theme-toggle').addEventListener('click', toggleTheme); document.getElementById('nav-filter').addEventListener('change', updateNavPanel); document.getElementById('prev-result').addEventListener('click', showPreviousResult); document.getElementById('next-result').addEventListener('click', showNextResult); document.getElementById('results-nav-toggle').addEventListener('click', toggleResultsNavPanel); document.getElementById('close-results-nav').addEventListener('click', toggleResultsNavPanel); document.getElementById('results-nav-filter').addEventListener('change', updateResultsNavPanel); debugLog("Quiz initialized successfully"); } catch (e) { console.error("Failed to initialize quiz:", e); debugLog("Failed to initialize quiz: " + e.message); document.getElementById('error-message').innerHTML = "Error initializing quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('start-test').disabled = true; } } // Start quiz function startQuiz() { try { debugLog("Starting quiz"); document.getElementById('instructions').classList.add('hidden'); document.getElementById('quiz').classList.remove('hidden'); showQuestion(currentQuestion); startTimer(); updateNavPanel(); debugLog("Quiz started successfully"); } catch (e) { console.error("Error starting quiz:", e); debugLog("Failed to start quiz: " + e.message); document.getElementById('error-message').innerHTML = "Error starting quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('quiz').classList.add('hidden'); document.getElementById('instructions').classList.remove('hidden'); } } // Show question function showQuestion(index) { try { debugLog(`Showing question ${index + 1}`); currentQuestion = index; const q = questions[index]; if (!q) { throw new Error(`Question ${index} is undefined`); } document.getElementById('question-number').innerHTML = `Question <span>${index + 1}</span> of ${questions.length}`; document.getElementById('question-text').innerHTML = q.text || "No question text available"; const imagesDiv = document.getElementById('question-images'); imagesDiv.innerHTML = q.question_images && q.question_images.length > 0 ? q.question_images.map(url => `<img src="${url}" alt="Question Image" class="max-w-full h-auto rounded-lg">`).join('') : ''; const optionsDiv = document.getElementById('options'); optionsDiv.innerHTML = q.options && q.options.length > 0 ? q.options.map(opt => ` <button class="option-btn w-full text-left p-3 border rounded-lg ${answers[index] === opt.label ? 'selected' : ''}" onclick="selectOption(${index}, '${opt.label}')" aria-label="Option ${opt.label}: ${opt.text}"> ${opt.label}. ${opt.text} </button> `).join('') : '<p class="text-red-500">No options available</p>'; document.getElementById('previous-btn').disabled = index === 0; document.getElementById('next-btn').disabled = index === questions.length - 1; document.getElementById('mark-review').classList.toggle('marked', markedForReview[index]); updateProgressBar(); saveProgress(); window.scrollTo({ top: 0, behavior: 'smooth' }); debugLog(`Question ${index + 1} displayed successfully`); } catch (e) { console.error("Error displaying question:", e); debugLog("Failed to display question: " + e.message); } } // Select option function selectOption(index, label) { try { debugLog(`Selecting option ${label} for question ${index + 1}`); answers[index] = label; const optionsDiv = document.getElementById('options'); const optionButtons = optionsDiv.querySelectorAll('.option-btn'); optionButtons.forEach(btn => { const btnLabel = btn.textContent.trim().split('.')[0]; btn.classList.toggle('selected', btnLabel === label); }); updateNavPanel(); saveProgress(); debugLog(`Option ${label} selected for question ${index + 1}`); } catch (e) { console.error("Error selecting option:", e); debugLog("Failed to select option: " + e.message); } } // Toggle mark for review function toggleMarkForReview() { try { debugLog(`Toggling mark for review on question ${currentQuestion + 1}`); markedForReview[currentQuestion] = !markedForReview[currentQuestion]; document.getElementById('mark-review').classList.toggle('marked', markedForReview[currentQuestion]); updateNavPanel(); saveProgress(); debugLog(`Mark for review toggled for question ${currentQuestion + 1}`); } catch (e) { console.error("Error marking for review:", e); debugLog("Failed to mark for review: " + e.message); } } // Navigate to previous question function showPreviousQuestion() { try { debugLog(`Navigating to previous question from ${currentQuestion + 1}`); if (currentQuestion > 0) { currentQuestion--; showQuestion(currentQuestion); } } catch (e) { console.error("Error navigating to previous question:", e); debugLog("Failed to navigate to previous question: " + e.message); } } // Navigate to next question function showNextQuestion() { try { debugLog(`Navigating to next question from ${currentQuestion + 1}`); if (currentQuestion < questions.length - 1) { currentQuestion++; showQuestion(currentQuestion); } } catch (e) { console.error("Error navigating to next question:", e); debugLog("Failed to navigate to next question: " + e.message); } } // Handle question navigation click function handleQuestionNavClick(index) { try { debugLog(`Navigating to question ${index + 1} via nav panel`); showQuestion(index); toggleNavPanel(); } catch (e) { console.error("Error handling navigation click:", e); debugLog("Failed to navigate via nav panel: " + e.message); } } // Start timer function startTimer() { try { debugLog("Starting timer"); timerInterval = setInterval(() => { if (timeRemaining <= 0) { debugLog("Timer expired, submitting test"); clearInterval(timerInterval); submitTest(); } else { timeRemaining--; const minutes = Math.floor(timeRemaining / 60); const seconds = timeRemaining % 60; document.getElementById('timer').innerHTML = `Time Remaining: <span>${minutes.toString().padStart(2, '0')}:${seconds.toString().padStart(2, '0')}</span>`; saveProgress(); } }, 1000); debugLog("Timer started successfully"); } catch (e) { console.error("Error starting timer:", e); debugLog("Failed to start timer: " + e.message); } } // Update progress bar function updateProgressBar() { try { debugLog("Updating progress bar"); const progress = ((currentQuestion + 1) / questions.length) * 100; document.getElementById('progress-bar').style.width = `${progress}%`; debugLog("Progress bar updated"); } catch (e) { console.error("Error updating progress bar:", e); debugLog("Failed to update progress bar: " + e.message); } } // Update quiz navigation panel function updateNavPanel() { try { debugLog("Updating quiz navigation panel"); const filter = document.getElementById('nav-filter').value; const navGrid = document.getElementById('nav-grid'); navGrid.innerHTML = questions.map((_, i) => { if (filter === 'answered' && !answers[i]) return ''; if (filter === 'unanswered' && answers[i]) return ''; if (filter === 'marked' && !markedForReview[i]) return ''; return ` <button class="question-nav-btn ${answers[i] ? 'answered' : 'unanswered'} ${markedForReview[i] ? 'marked-nav' : ''}" onclick="handleQuestionNavClick(${i})" aria-label="Go to Question ${i + 1}"> ${i + 1} </button> `; }).join(''); debugLog("Quiz navigation panel updated"); } catch (e) { console.error("Error updating quiz navigation panel:", e); debugLog("Failed to update quiz navigation panel: " + e.message); } } // Update results navigation panel function updateResultsNavPanel() { try { debugLog("Updating results navigation panel"); const filter = document.getElementById('results-nav-filter').value; const navGrid = document.getElementById('results-nav-grid'); navGrid.innerHTML = questions.map((_, i) => { if (filter === 'answered' && !answers[i]) return ''; if (filter === 'unanswered' && answers[i]) return ''; if (filter === 'marked' && !markedForReview[i]) return ''; return ` <button class="result-nav-btn-grid ${answers[i] ? 'answered' : 'unanswered'} ${markedForReview[i] ? 'marked-nav' : ''}" onclick="handleResultNavClick(${i})" aria-label="Go to Result for Question ${i + 1}"> ${i + 1} </button> `; }).join(''); debugLog("Results navigation panel updated"); } catch (e) { console.error("Error updating results navigation panel:", e); debugLog("Failed to update results navigation panel: " + e.message); } } // Toggle quiz navigation panel function toggleNavPanel() { try { debugLog("Toggling quiz navigation panel"); const navPanel = document.getElementById('nav-panel'); navPanel.classList.toggle('hidden'); debugLog("Quiz navigation panel toggled"); } catch (e) { console.error("Error toggling quiz navigation panel:", e); debugLog("Failed to toggle quiz navigation panel: " + e.message); } } // Toggle results navigation panel function toggleResultsNavPanel() { try { debugLog("Toggling results navigation panel"); const resultsNavPanel = document.getElementById('results-nav-panel'); resultsNavPanel.classList.toggle('hidden'); if (!resultsNavPanel.classList.contains('hidden')) { updateResultsNavPanel(); } debugLog("Results navigation panel toggled"); } catch (e) { console.error("Error toggling results navigation panel:", e); debugLog("Failed to toggle results navigation panel: " + e.message); } } // Handle result navigation click function handleResultNavClick(index) { try { debugLog(`Navigating to result for question ${index + 1} via nav panel`); showResults(index); toggleResultsNavPanel(); } catch (e) { console.error("Error handling result navigation click:", e); debugLog("Failed to navigate to result: " + e.message); } } // Show submit modal function showSubmitModal() { try { debugLog("Showing submit modal"); const attempted = answers.filter(a => a !== null).length; document.getElementById('attempted-count').textContent = attempted; document.getElementById('unattempted-count').textContent = questions.length - attempted; document.getElementById('submit-modal').classList.remove('hidden'); debugLog("Submit modal displayed"); } catch (e) { console.error("Error showing submit modal:", e); debugLog("Failed to show submit modal: " + e.message); } } // Close submit modal function closeSubmitModal() { try { debugLog("Closing submit modal"); document.getElementById('submit-modal').classList.add('hidden'); debugLog("Submit modal closed"); } catch (e) { console.error("Error closing submit modal:", e); debugLog("Failed to close submit modal: " + e.message); } } // Close exit modal function closeExitModal() { try { debugLog("Closing exit modal"); document.getElementById('exit-modal').classList.add('hidden'); debugLog("Exit modal closed"); } catch (e) { console.error("Error closing exit modal:", e); debugLog("Failed to close exit modal: " + e.message); } } // Submit test function submitTest() { try { debugLog("Submitting test"); clearInterval(timerInterval); document.getElementById('quiz').classList.add('hidden'); document.getElementById('submit-modal').classList.add('hidden'); document.getElementById('results').classList.remove('hidden'); showResults(0); // Start with first question // Trigger confetti animation confetti({ particleCount: 100, spread: 70, origin: { y: 0.6 } }); localStorage.removeItem(`quiz_${quizId}`); debugLog("Test submitted successfully"); } catch (e) { console.error("Error submitting test:", e); debugLog("Failed to submit test: " + e.message); } } // Show result for a single question function showResults(index) { try { debugLog(`Showing result for question ${index + 1}`); currentResultQuestion = index; let correct = 0, wrong = 0, unanswered = 0, marked = 0; answers.forEach((answer, i) => { const isCorrect = answer && questions[i].options.find(opt => opt.label === answer)?.correct; if (answer === null) unanswered++; else if (isCorrect) correct++; else wrong++; if (markedForReview[i]) marked++; }); const q = questions[index]; if (!q) { throw new Error(`Question ${index} is undefined`); } const userAnswer = answers[index]; const isCorrect = userAnswer && q.options.find(opt => opt.label === userAnswer)?.correct; const resultsContent = document.getElementById('results-content'); resultsContent.innerHTML = ` <div class="border p-4 rounded-lg ${isCorrect ? 'bg-green-50' : userAnswer ? 'bg-red-50' : 'bg-gray-50'}"> <p class="font-semibold">Question ${index + 1}: ${q.text || 'No question text'}</p> ${q.question_images && q.question_images.length > 0 ? q.question_images.map(url => `<img src="${url}" alt="Question Image" class="max-w-full h-auto rounded-lg my-2">`).join('') : ''} <p><strong>Your Answer:</strong> ${userAnswer ? `${userAnswer}. ${q.options.find(opt => opt.label === userAnswer)?.text || 'Invalid option'}` : 'Unanswered'}</p> <p><strong>Correct Answer:</strong> ${q.correct_answer || 'Unknown'}</p> <div class="mt-2">${q.explanation || 'No explanation available'}</div> ${q.explanation_images && q.explanation_images.length > 0 ? q.explanation_images.map(url => `<img src="${url}" alt="Explanation Image" class="max-w-full h-auto rounded-lg my-2">`).join('') : ''} ${q.video ? ` <button class="play-video bg-blue-500 text-white px-4 py-2 rounded-lg mt-2" onclick="loadVideo(this, '${q.video}', 'video-${index}')" aria-label="Play explanation video for Question ${index + 1}"> Play Video Explanation </button> <div id="video-${index}" class="video-container mt-2"></div> ` : '<p class="text-gray-500 mt-2">No video available</p>'} ${q.audio ? ` <button class="play-audio bg-blue-500 text-white px-4 py-2 rounded-lg mt-2" onclick="loadAudio(this, '${q.audio}', 'audio-${index}')" aria-label="Play audio explanation for Question ${index + 1}"> Play Audio Explanation </button> <div id="audio-${index}" class="audio-container mt-2"></div> ` : ''} </div> `; document.getElementById('correct-count').textContent = correct; document.getElementById('wrong-count').textContent = wrong; document.getElementById('unanswered-count').textContent = unanswered; document.getElementById('marked-count').textContent = marked; document.getElementById('result-question-number').innerHTML = `Question <span>${index + 1}</span> of ${questions.length}`; document.getElementById('prev-result').disabled = index === 0; document.getElementById('next-result').disabled = index === questions.length - 1; updateResultsNavPanel(); window.scrollTo({ top: 0, behavior: 'smooth' }); debugLog(`Result for question ${index + 1} displayed successfully`); } catch (e) { console.error("Error displaying result:", e); debugLog("Failed to display result: " + e.message); } } // Navigate to previous result function showPreviousResult() { try { debugLog(`Navigating to previous result from question ${currentResultQuestion + 1}`); if (currentResultQuestion > 0) { showResults(currentResultQuestion - 1); } } catch (e) { console.error("Error navigating to previous result:", e); debugLog("Failed to navigate to previous result: " + e.message); } } // Navigate to next result function showNextResult() { try { debugLog(`Navigating to next result from question ${currentResultQuestion + 1}`); if (currentResultQuestion < questions.length - 1) { showResults(currentResultQuestion + 1); } } catch (e) { console.error("Error navigating to next result:", e); debugLog("Failed to navigate to next result: " + e.message); } } // Lazy-load video function loadVideo(button, videoUrl, containerId) { try { debugLog(`Loading video for ${containerId}: ${videoUrl}`); if (!videoUrl) { const container = document.getElementById(containerId); container.innerHTML = `<p class="text-gray-500">No video available</p>`; button.remove(); debugLog("No video URL provided"); return; } const container = document.getElementById(containerId); container.innerHTML = ` <div class="video-loading"></div> <video controls class="w-full max-w-[600px] rounded-lg" preload="metadata" aria-label="Video explanation"> <source src="${videoUrl}" type="${videoUrl.endsWith('.m3u8') ? 'application/x-mpegURL' : 'video/mp4'}"> Your browser does not support the video tag. </video> `; container.classList.add('active'); button.remove(); // Initialize HLS.js for .m3u8 videos const video = container.querySelector('video'); if (videoUrl.endsWith('.m3u8') && Hls.isSupported()) { const hls = new Hls(); hls.loadSource(videoUrl); hls.attachMedia(video); hls.on(Hls.Events.ERROR, (event, data) => { console.error("HLS.js error:", data); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; debugLog("HLS.js error: " + JSON.stringify(data)); }); } else if (videoUrl.endsWith('.m3u8') && video.canPlayType('application/vnd.apple.mpegurl')) { video.src = videoUrl; } // Handle video load errors video.onerror = () => { console.error("Video load error for URL:", videoUrl); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; debugLog("Video load error for URL: " + videoUrl); }; // Remove loading spinner when video is ready video.onloadedmetadata = () => { container.querySelector('.video-loading').remove(); debugLog("Video loaded successfully"); }; } catch (e) { console.error("Error loading video:", e); debugLog("Failed to load video: " + e.message); const container = document.getElementById(containerId); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; } } // Lazy-load audio function loadAudio(button, audioUrl, containerId) { try { debugLog(`Loading audio for ${containerId}: ${audioUrl}`); if (!audioUrl) { const container = document.getElementById(containerId); container.innerHTML = `<p class="text-gray-500">No audio available</p>`; button.remove(); debugLog("No audio URL provided"); return; } const container = document.getElementById(containerId); container.innerHTML = ` <audio controls class="w-full max-w-[600px]" preload="metadata" aria-label="Audio explanation"> <source src="${audioUrl}" type="audio/mpeg"> Your browser does not support the audio tag. </audio> `; container.classList.add('active'); button.remove(); // Handle audio load errors const audio = container.querySelector('audio'); audio.onerror = () => { console.error("Audio load error for URL:", audioUrl); container.innerHTML = `<p class="text-red-500">Error loading audio. <a href="${audioUrl}" target="_blank" aria-label="Open audio in new tab">Open audio</a></p>`; debugLog("Audio load error for URL: " + audioUrl); }; debugLog("Audio loaded successfully"); } catch (e) { console.error("Error loading audio:", e); debugLog("Failed to load audio: " + e.message); const container = document.getElementById(containerId); container.innerHTML = `<p class="text-red-500">Error loading audio. <a href="${audioUrl}" target="_blank" aria-label="Open audio in new tab">Open audio</a></p>`; } } // Toggle dark mode function toggleTheme() { try { debugLog("Toggling theme"); document.documentElement.classList.toggle('dark'); localStorage.setItem('theme', document.documentElement.classList.contains('dark') ? 'dark' : 'light'); debugLog("Theme toggled successfully"); } catch (e) { console.error("Error toggling theme:", e); debugLog("Failed to toggle theme: " + e.message); } } // Load theme preference function loadTheme() { try { debugLog("Loading theme preference"); const theme = localStorage.getItem('theme'); if (theme === 'dark') { document.documentElement.classList.add('dark'); } debugLog("Theme loaded successfully"); } catch (e) { console.error("Error loading theme:", e); debugLog("Failed to load theme: " + e.message); } } // Initialize on DOM content loaded window.addEventListener('DOMContentLoaded', () => { try { debugLog("DOM content loaded, initializing quiz"); loadTheme(); initQuiz(); } catch (e) { console.error("Error during DOMContentLoaded:", e); debugLog("Failed to initialize on DOMContentLoaded: " + e.message); document.getElementById('error-message').innerHTML = "Error initializing quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); } }); </script> </body> </html>" frameborder="0" width="100%" height="2000px">
<div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <h2 class="text-xl font-semibold mb-4">Instructions</h2> <h4 class="text-gray-800 text-lg font-semibold mt-6 mb-4">Test Features:</h4> <ul class="space-y-3"> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Multiple choice questions with single correct answers </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Timer-based testing for realistic exam conditions </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Mark questions for review functionality </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Comprehensive results and performance analysis </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Mobile-optimized interface for learning on-the-go </li> </ul> <div class="mt-6 flex space-x-4 button-group md:flex-row flex-col"> <button class="bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="start-test">Start Test</button> </div> <div class="error-message hidden" id="error-message"></div> </div> </section> <!-- Quiz Section --> <section class="container mx-auto px-4 md:px-6 pt-4 md:pt-6 pb-1 hidden section-transition" id="quiz"> <div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <!-- Progress Bar --> <div class="w-full bg-gray-200 rounded-full h-3 mb-4"> <div class="progress-bar h-3 rounded-full" id="progress-bar" style="width: 0%"></div> </div> <!-- Question Header --> <div class="flex flex-col md:flex-row justify-between items-center mb-4"> <h2 class="text-lg font-semibold" id="question-number">Question <span>1</span> of 4</h2> <p class="text-lg font-semibold mt-2 md:mt-0" id="timer">Time Remaining: <span>00:00</span></p> </div> <!-- Question Content --> <div class="mb-6" id="question-content"> <p class="text-gray-800 mb-4" id="question-text"></p> <div class="flex flex-wrap gap-4 mb-4" id="question-images"></div> <div class="space-y-3" id="options"></div> </div> <!-- Navigation Buttons --> <div class="flex flex-col md:flex-row justify-between items-center gap-2 md:gap-4"> <div class="flex gap-2 w-full md:w-auto"> <button class="bg-[#2c5281] text-white px-4 py-3 w-full md:w-32 h-14 rounded-lg hover:bg-[#2c5281] transition" disabled="" id="previous-btn">Previous</button> <button class="bg-[#2c5281] text-white px-4 py-3 w-full md:w-32 h-14 rounded-lg hover:bg-[#2c5281] transition" id="next-btn">Next</button> </div> <div class="flex items-center gap-2"> <button class="bg-transparent text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-100 transition flex items-center gap-1" id="mark-review"> Review <svg xmlns="http://www.w3.org/2000/svg" class="h-5 w-5" viewBox="0 0 20 20" fill="currentColor"> <path d="M10 2a1 1 0 00-1 1v14l3.293-3.293a1 1 0 011.414 0L17 17V3a1 1 0 00-1-1H10z" /> </svg> </button> <button class="bg-transparent text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-100 transition flex items-center gap-1" id="nav-toggle"> Question 🧭 </button> <button class="bg-green-500 text-white px-6 py-3 w-44 h-14 rounded-lg hover:bg-green-600 transition w-full md:w-auto" id="submit-test">Submit Test</button> </div> </div> </section> <!-- Results Section --> <section class="container mx-auto px-4 md:px-6 pt-4 md:pt-6 pb-1 hidden section-transition" id="results"> <div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <h2 class="text-2xl font-semibold mb-4">Anaesthesia Machine - Results</h2> <div class="grid grid-cols-1 md:grid-cols-2 gap-4 mb-6"> <p><strong>Correct:</strong> <span id="correct-count" class="text-[#000000]">0</span></p> <p><strong>Wrong:</strong> <span id="wrong-count" class="text-[#000000]">0</span></p> <p><strong>Unanswered:</strong> <span id="unanswered-count" class="text-[#000000]-500">0</span></p> <p><strong>Marked for Review:</strong> <span id="marked-count" class="text-[#000000]">0</span></p> </div> <h3 class="text-lg font-semibold mb-4" id="result-question-number">Question <span>1</span> of 4</h3> <div class="space-y-6" id="results-content"></div> <div class="result-nav"> <button aria-label="Previous question result" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" disabled="" id="prev-result">Previous</button> <button aria-label="Toggle results navigation panel" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="results-nav-toggle">Result 🧭</button> <button aria-label="Next question result" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="next-result">Next</button> </div> <div class="mt-6 flex space-x-4 button-group md:flex-row flex-col"> <button class="bg-green-500 text-white px-6 py-2 rounded-lg hover:bg-green-600 transition" id="take-again">Take Again</button> </div> </div> </section> <!-- Exit Confirmation Modal --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 hidden" id="exit-modal" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white rounded-lg p-6 max-w-sm w-full"> <h2 class="text-xl font-semibold mb-4">Leave Test?</h2> <p class="text-gray-700 mb-4">Your progress will be lost if you leave this page. Are you sure you want to exit?</p> <div class="flex justify-end space-x-4"> <button class="bg-gray-300 text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-400 transition" id="continue-test">No, Continue</button> <button class="bg-red-500 text-white px-4 py-2 rounded-lg hover:bg-red-600 transition" id="exit-test">Yes, Exit</button> </div> </div> </div> <!-- Submit Confirmation Modal --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 hidden" id="submit-modal" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white rounded-lg p-6 max-w-sm w-full"> <h2 class="text-xl font-semibold mb-4">Confirm Submission</h2> <p class="text-gray-700 mb-2">You have attempted <span id="attempted-count">0</span> of 4 questions.</p> <p class="text-gray-700 mb-4"><span id="unattempted-count">0</span> questions are unattempted.</p> <div class="flex justify-end space-x-4"> <button class="bg-gray-300 text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-400 transition" id="cancel-submit">Cancel</button> <button class="text-white px-4 py-2 rounded-lg hover:bg-[#1a365d] transition" style="background-color: #2c5281;" id="confirm-submit">Submit Test</button> </div> </div> </div> <!-- Quiz Navigation Panel --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 z-50 nav-panel hidden overflow-y-auto" id="nav-panel" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white shadow-lg p-4 rounded-lg w-full max-w-2xl max-h-[80vh] overflow-y-auto"> <h2 class="text-lg font-semibold mb-4">Questions Navigation</h2> <div class="mb-4"> <select class="w-full p-2 border rounded-lg text-gray-700" id="nav-filter"> <option value="all">All Questions</option> <option value="answered">Answered</option> <option value="unanswered">Unanswered</option> <option value="marked">Marked for Review</option> </select> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-nav">Close</button> </div> </div> <!-- Results Navigation Panel --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 z-50 results-nav-panel hidden overflow-y-auto" id="results-nav-panel" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white shadow-lg p-4 rounded-lg w-full max-w-2xl max-h-[80vh] overflow-y-auto"> <h2 class="text-lg font-semibold mb-4">Results Navigation</h2> <div class="mb-4"> <select class="w-full p-2 border rounded-lg text-gray-700" id="results-nav-filter"> <option value="all">All Questions</option> <option value="answered">Answered</option> <option value="unanswered">Unanswered</option> <option value="marked">Marked for Review</option> </select> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="results-nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-results-nav">Close</button> </div> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="results-nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-results-nav">Close</button> </div> <!-- JavaScript Logic --> <script> // Enable debug mode for detailed logging const DEBUG_MODE = true; // Log debug messages function debugLog(message) { if (DEBUG_MODE) { console.log(`[DEBUG] ${message}`); } } // Initialize questions with error handling let questions = []; let currentResultQuestion = 0; // State for current question in results try { debugLog("Attempting to parse questions_json"); questions = [{"text": "A neonate is presented with bilious vomiting since birth. Abdominal exam is essentially normal. Anal opening is normal. What will be the treatment in the neonate showing the below abdominal X ray?", "options": [{"label": "A", "text": "Gastroduodenostomy", "correct": false}, {"label": "B", "text": "Duodeno-duodenostomy", "correct": true}, {"label": "C", "text": "Gastrojejunostomy", "correct": false}, {"label": "D", "text": "Duodenojejunostomy", "correct": false}], "correct_answer": "B. Duodeno-duodenostomy", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/27/picture19.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B) Duodeno-duodenostomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• The above X ray shows Double Bubble sign seen in Duodenal atresia .</li><li>• X ray shows Double Bubble sign seen in Duodenal atresia</li><li>• The appropriate surgical treatment for a neonate diagnosed with duodenal atresia , as indicated by a \"Double Bubble\" sign on an abdominal X-ray , is a duodeno-duodenostomy, which connects the pre- and post-atretic portions of the duodenum , also called as Open Kimura duodeno-duodenostomy</li><li>• surgical treatment for a neonate diagnosed with duodenal atresia</li><li>• \"Double Bubble\" sign</li><li>• abdominal X-ray</li><li>• duodeno-duodenostomy,</li><li>• connects the pre- and post-atretic portions of the duodenum</li><li>• Open Kimura duodeno-duodenostomy</li><li>• The obstruction in duodenal atresia usually lies just distal to the ampulla of Vater. Neonate is brought with bilious vomiting. Associated with Down’s syndrome Diagnosis: ‘Double bubble’ sign on Xray Surgical repair: Open Kimura duodenoduodenostomy</li><li>• The obstruction in duodenal atresia usually lies just distal to the ampulla of Vater.</li><li>• Neonate is brought with bilious vomiting.</li><li>• Associated with Down’s syndrome</li><li>• Diagnosis: ‘Double bubble’ sign on Xray</li><li>• Surgical repair: Open Kimura duodenoduodenostomy</li><li>• Ref : Bailey and Love’s short practice of surgery 28 th edition pg 266</li><li>• Ref</li><li>• : Bailey and Love’s short practice of surgery 28 th edition pg 266</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the incorrect statement about pediatric surgical principles in contrast to adults:", "options": [{"label": "A", "text": "Wider abdomen with reduced vertical distance", "correct": false}, {"label": "B", "text": "Bladder is mainly intra-peritoneal", "correct": false}, {"label": "C", "text": "Ribs are more horizontal and rigid", "correct": true}, {"label": "D", "text": "Liver is lower down than in an adult", "correct": false}], "correct_answer": "C. Ribs are more horizontal and rigid", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-113701.png"], "explanation": "<p><strong>Ans. C) Ribs are more horizontal and rigid</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Wider Abdomen with Reduced Vertical Distance : Pediatric patients often have a proportionally wider abdomen and a broader costal margin compared to adults . This anatomical difference implies that transverse supraumbilical incisions may offer better surgical access than vertical midline incisions, due to the different shape and distribution of abdominal organs.</li><li>• Option A.</li><li>• Wider Abdomen with Reduced Vertical Distance</li><li>• Pediatric patients</li><li>• proportionally wider abdomen</li><li>• broader costal margin compared to adults</li><li>• Option B. Bladder is mainly intra-peritoneal : In infants and young children , the bladder is located higher in the abdomen and is partly intra-abdominal , which places it at greater risk for injury during abdominal trauma or surgical procedures. This necessitates extra caution during interventions.</li><li>• Option B.</li><li>• Bladder is mainly intra-peritoneal</li><li>• infants and young children</li><li>• bladder is located higher in the abdomen</li><li>• partly intra-abdominal</li><li>• places it at greater risk for injury during abdominal trauma</li><li>• Option D. Liver is Lower Down than in an Adult : In children, the liver edge extends below the costal margin , making it more susceptible to injury from abdominal trauma and surgical incisions . This anatomical consideration is crucial when planning surgical approaches and in the assessment of trauma patients.</li><li>• Option D.</li><li>• Liver is Lower Down than in an Adult</li><li>• liver edge extends below the costal margin</li><li>• more susceptible to injury from abdominal trauma and surgical incisions</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Ref : Bailey 28 th Ed. Table 17.1</li><li>➤ Ref</li><li>➤ :</li><li>➤ Bailey 28 th Ed. Table 17.1</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A child delivered at 9 months of gestation is found to have respiratory distress, scaphoid abdomen and gurgling sounds in chest on auscultation by the neonatalogist. What is the next step to be done in this condition?", "options": [{"label": "A", "text": "Bag and mask ventilation", "correct": false}, {"label": "B", "text": "CT chest and abdomen", "correct": false}, {"label": "C", "text": "X ray chest", "correct": true}, {"label": "D", "text": "Exploratory laparotomy", "correct": false}], "correct_answer": "C. X ray chest", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) X ray chest</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Bag and Mask Ventilation : This is usually the first response in respiratory distress to ensure oxygenation. However, in suspected cases of congenital diaphragmatic hernia (CDH), this could worsen the condition by increasing air in the gastrointestinal tract and further displacing the abdominal contents into the thoracic cavity , and is contraindicated .</li><li>• Option A.</li><li>• Bag and Mask Ventilation</li><li>• this could worsen the condition by increasing air in the gastrointestinal tract and further displacing the abdominal contents into the thoracic cavity</li><li>• and is contraindicated</li><li>• Option B. CT Chest and Abdomen : While CT scans provide detailed images, they are not the first-line investigation in emergency settings due to the time they take and the need for patient stabilization prior to the imaging.</li><li>• Option B.</li><li>• CT Chest and Abdomen</li><li>• not the first-line investigation in emergency settings</li><li>• Option D. Exploratory Laparotomy : Surgical intervention is necessary for CDH but is not the first immediate step . The newborn must be stabilized with appropriate respiratory support before any surgical correction is considered.</li><li>• Option D.</li><li>• Exploratory Laparotomy</li><li>• Surgical intervention</li><li>• CDH but is not the first immediate step</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ For a newborn presenting with signs of congenital diaphragmatic hernia , the immediate step is to perform a chest X-ray to confirm the diagnosis and avoid bag and mask ventilation which can exacerbate the condition.</li><li>➤ newborn presenting with signs of congenital diaphragmatic hernia</li><li>➤ step is to perform a chest X-ray to confirm the diagnosis</li><li>➤ avoid bag</li><li>➤ mask ventilation</li><li>➤ MC Type of CDH-left posterolateral or Bochdalek defect Other site: Right anterior or Morgagni defect Antenatal diagnosis – Ultrasound Postnatal diagnosis – clinical features and Xray chest to see bowel loops in thoracic cavity- if needed then CT Thorax + abdomen Management after delivery of child - After birth, intubation, muscle relaxation and gentle ventilation aim to maintain pH, and oxygen saturation so avoiding right-to-left shunting. Avoid bag and mask ventilation Surgical repair is done after 48 hours after child is stabilized</li><li>➤ MC Type of CDH-left posterolateral or Bochdalek defect</li><li>➤ Other site: Right anterior or Morgagni defect</li><li>➤ Antenatal diagnosis – Ultrasound</li><li>➤ Postnatal diagnosis – clinical features and Xray chest to see bowel</li><li>➤ loops in thoracic cavity- if needed then CT Thorax + abdomen</li><li>➤ Management after delivery of child - After birth, intubation, muscle relaxation and gentle ventilation aim to maintain pH, and oxygen saturation so avoiding right-to-left shunting. Avoid bag and mask ventilation</li><li>➤ Avoid bag and mask ventilation</li><li>➤ Surgical repair is done after 48 hours after child is stabilized</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 271</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 271</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these are the most important prognostic factors in congenital diaphgramatic hernia?", "options": [{"label": "A", "text": "Presence of liver in thoracic cavity", "correct": false}, {"label": "B", "text": "Pulmonary hypertension and pulmonary hypoplasia", "correct": true}, {"label": "C", "text": "Early respiratory distress", "correct": false}, {"label": "D", "text": "Size of the diaphragmatic opening", "correct": false}], "correct_answer": "B. Pulmonary hypertension and pulmonary hypoplasia", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Pulmonary hypertension and pulmonary hypoplasia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Presence of Liver in Thoracic Cavity : While the herniation of the liver into the thoracic cavity can be associated with a worse prognosis due to the space-occupying effect it has, leading to further lung compression, it is not the most important prognostic factor.</li><li>• Option A.</li><li>• Presence of Liver in Thoracic Cavity</li><li>• herniation of the liver</li><li>• thoracic cavity</li><li>• worse prognosis due to the space-occupying effect</li><li>• Option C. Early Respiratory Distress : While early respiratory distress is a common presentation of CDH and indicates a need for immediate medical intervention, it is not a direct prognostic factor . The severity of the respiratory distress may correlate with the underlying lung hypoplasia and pulmonary hypertension but on its own, does not determine the prognosis.</li><li>• Option C.</li><li>• Early Respiratory Distress</li><li>• common presentation of CDH and indicates a need for immediate medical intervention,</li><li>• not a direct prognostic factor</li><li>• Option D. Size of the Diaphragmatic Opening : Although the size of the diaphragmatic defect may influence the degree of herniation and potentially the severity of pulmonary hypoplasia , it is not as critical a prognostic factor as the development of pulmonary hypertension and the degree of pulmonary hypoplasia.</li><li>• Option D.</li><li>• Size of the Diaphragmatic Opening</li><li>• influence the degree of herniation and potentially the severity of pulmonary hypoplasia</li><li>• not as critical a prognostic factor</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ MC organ to herniate through hernia – Transverse colon Complication: Pulmonary hypoplasia due to compression and pulmonary hypertension due to increased thickness of arteriolar smooth muscle Most important prognostic factors: Pulmonary hypertension and pulmonary hypoplasia</li><li>➤ MC organ to herniate through hernia – Transverse colon</li><li>➤ MC organ to herniate through hernia</li><li>➤ Complication: Pulmonary hypoplasia due to compression and pulmonary hypertension due to increased thickness of arteriolar smooth muscle</li><li>➤ Complication:</li><li>➤ Most important prognostic factors: Pulmonary hypertension and pulmonary hypoplasia</li><li>➤ Most important prognostic factors:</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 271</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 271</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A child is born with the defect shown in the picture below. Identify the condition:", "options": [{"label": "A", "text": "Omphalocoele", "correct": false}, {"label": "B", "text": "Gastrochisis", "correct": true}, {"label": "C", "text": "Ectopia vesicae", "correct": false}, {"label": "D", "text": "Midgut voluvulus", "correct": false}], "correct_answer": "B. Gastrochisis", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/27/untitled-10.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B) Gastrochisis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A . Omphalocele : Characterized by herniation of abdominal contents into the base of the umbilical cord , this condition presents with organs enclosed in a peritoneal sac , distinguishing it from the defect observed in the image.</li><li>• Option</li><li>• A</li><li>• Omphalocele</li><li>• herniation of abdominal contents into the base of the umbilical cord</li><li>• organs enclosed in a peritoneal sac</li><li>• Option C. Ectopia Vesicae (Exstrophy of the Bladder) : This is a lower abdominal wall defect involving the bladder, where the bladder is exposed on the abdomen . The condition in the image does not depict this.</li><li>• Option C.</li><li>• Ectopia Vesicae (Exstrophy of the Bladder)</li><li>• lower abdominal wall defect</li><li>• bladder,</li><li>• bladder is exposed on the abdomen</li><li>• Option D. Midgut Volvulus : A condition where the intestines are twisted, leading potentially to bowel obstruction and ischemia . It is an internal disorder and would not be visible externally as in the image provided.</li><li>• Option D.</li><li>• Midgut Volvulus</li><li>• intestines are twisted, leading potentially to bowel obstruction and ischemia</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Gastroschisis is an abdominal wall defect to the right side umbilical cord without a peritoneal covering , identified by exposed intestines and other organs at birth , requiring immediate medical intervention.</li><li>➤ Gastroschisis</li><li>➤ abdominal wall defect</li><li>➤ right side umbilical cord without a peritoneal covering</li><li>➤ exposed intestines and other organs at birth</li><li>➤ Risk factors include teenage pregnancy , recreational drugs, smoking and genitourinary infection in pregnancy. Usually occurs in isolation, without other abnormalities The abdomen and viscera are wrapped using a transparent plastic food wrap (e.g. cling film, Saran wrap), a large-bore nasogastric tube is placed , and fluid resuscitation is initiated . The bowel may have a thick wall and be matted together. Primary closure under general anaesthesia usually requires NICU admission for postoperative ventilation. An alternative is to place a preformed silo at the bedside, followed by gradual reduction, which sometimes avoids general anaesthesia altogether</li><li>➤ Risk factors include teenage pregnancy , recreational drugs, smoking and genitourinary infection in pregnancy.</li><li>➤ teenage pregnancy</li><li>➤ Usually occurs in isolation, without other abnormalities</li><li>➤ isolation, without other abnormalities</li><li>➤ The abdomen and viscera are wrapped using a transparent plastic food wrap (e.g. cling film, Saran wrap), a large-bore nasogastric tube is placed , and fluid resuscitation is initiated . The bowel may have a thick wall and be matted together. Primary closure under general anaesthesia usually requires NICU admission for postoperative ventilation.</li><li>➤ abdomen and viscera are wrapped</li><li>➤ transparent plastic food wrap</li><li>➤ large-bore nasogastric tube is placed</li><li>➤ fluid resuscitation is initiated</li><li>➤ An alternative is to place a preformed silo at the bedside, followed by gradual reduction, which sometimes avoids general anaesthesia altogether</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 270</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 270</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the incorrect statement about the condition in the image:", "options": [{"label": "A", "text": "The bowel is covered by 3 layers", "correct": false}, {"label": "B", "text": "Frequently associated with syndromes", "correct": false}, {"label": "C", "text": "Musculoskeletal anomalies are the most common associated defects", "correct": true}, {"label": "D", "text": "Exomphalos major requires staged repair", "correct": false}], "correct_answer": "C. Musculoskeletal anomalies are the most common associated defects", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/27/picture15.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Musculoskeletal anomalies are the most common associated defects</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. The bowel is covered by 3 layers : This is correct . In exomphalos (also known as omphalocele), the herniated abdominal contents are covered by a sac composed of the peritoneum, Wharton's jelly, and amnion.</li><li>• Option A.</li><li>• The bowel is covered by 3 layers</li><li>• correct</li><li>• Option B . Frequently associated with syndromes : This is also correct . Exomphalos can be associated with chromosomal abnormalities and various syndromes, particularly when the defect is large.</li><li>• Option B</li><li>• Frequently associated with syndromes</li><li>• correct</li><li>• Option D . Exomphalos major requires staged repair : This is correct . In cases of exomphalos major, where the defect is large (&gt;5 cm), often involving the liver, a staged repair or non-operative management allowing for epithelialization before closure is typically required.</li><li>• Option D</li><li>• Exomphalos major requires staged repair</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In exomphalos , also known as omphalocele, the herniated bowel is covered by a three-layered sac , with cardiac anomalies being more common than musculoskeletal defects , and larger defects may require a staged surgical approach.</li><li>➤ exomphalos</li><li>➤ omphalocele, the herniated bowel is covered by a three-layered sac</li><li>➤ cardiac anomalies</li><li>➤ common than musculoskeletal defects</li><li>➤ larger defects</li><li>➤ Exomphalos minor (&lt; 5 cm, liver not involved) is commonly associated with other anomalies ( cardiac malformations ) and the defect is easily closed. In exomphalos major , the sac can be dressed with a topical antibacterial agent (e.g. manuka honey, silver sulfadiazine), allowing epithelialisation and later closure or delayed closure of the ventral hernia. If an early closure of an exomphalos major is attempted, close observation for an abdominal compartment syndrome is mandated.</li><li>➤ Exomphalos minor (&lt; 5 cm, liver not involved) is commonly associated with other anomalies ( cardiac malformations ) and the defect is easily closed.</li><li>➤ Exomphalos minor</li><li>➤ cardiac malformations</li><li>➤ In exomphalos major , the sac can be dressed with a topical antibacterial agent (e.g. manuka honey, silver sulfadiazine), allowing epithelialisation and later closure or delayed closure of the ventral hernia.</li><li>➤ exomphalos major</li><li>➤ sac can be dressed with a topical antibacterial agent</li><li>➤ If an early closure of an exomphalos major is attempted, close observation for an abdominal compartment syndrome is mandated.</li><li>➤ Ref : 28 th Ed. Pg 270-271</li><li>➤ Ref</li><li>➤ :</li><li>➤ 28 th Ed. Pg 270-271</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 2-month-old child is brought to a pediatrician by parents with a history of crying. They claim to have noticed a bulge in his groin when he cries. The examination is essentially normal, except for a palpable thickening of the spermatic cord. What is the management?", "options": [{"label": "A", "text": "Reassurance and follow up", "correct": false}, {"label": "B", "text": "Anti-inflammatory drugs", "correct": false}, {"label": "C", "text": "Look for imperforate anus", "correct": false}, {"label": "D", "text": "Elective surgical exploration", "correct": true}], "correct_answer": "D. Elective surgical exploration", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Elective surgical exploration</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A. Reassurance and Follow Up : This approach might be considered for a congenital hydrocele for up to 2 years , but not a hernia.</li><li>• Option A.</li><li>• Reassurance and Follow Up</li><li>• considered for a congenital hydrocele for up to 2 years</li><li>• Option B. Anti-inflammatory Drugs : These are not indicated as they do not address the underlying issue of a potential inguinal hernia , which is a structural defect.</li><li>• Option B.</li><li>• Anti-inflammatory Drugs</li><li>• not indicated as they do not address the underlying issue of a potential inguinal hernia</li><li>• Option C. Look for Imperforate Anus : While it is important to assess for associated anomalies in pediatric cases , the presenting complaint and physical findings do not suggest an imperforate anus, which typically presents with failure to pass meconium, not intermittent groin bulge.</li><li>• Option C.</li><li>• Look for Imperforate Anus</li><li>• important to assess for associated anomalies in pediatric cases</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In the presence of intermittent groin bulge and a palpable thickened spermatic cord in an infant , the appropriate management is elective surgical exploration to address a likely congenital inguinal hernia.</li><li>➤ presence of intermittent groin bulge and a palpable thickened spermatic cord in an infant</li><li>➤ management is elective surgical exploration</li><li>➤ Ages of repair of pediatric groin conditions:</li><li>➤ Ages of repair of pediatric groin conditions:</li><li>➤ Congenital inguinal hernia: Elective/Early repair at diagnosis Congenital hydrocele: Herniotomy at 2 years Undescended testes: Orchidopexy by 6 months</li><li>➤ Congenital inguinal hernia: Elective/Early repair at diagnosis</li><li>➤ Congenital inguinal hernia: Elective/Early repair at diagnosis</li><li>➤ Congenital hydrocele: Herniotomy at 2 years</li><li>➤ Congenital hydrocele: Herniotomy at 2 years</li><li>➤ Undescended testes: Orchidopexy by 6 months</li><li>➤ Undescended testes: Orchidopexy by 6 months</li><li>➤ Ref : Bailey 28 th Ed. Pg 256</li><li>➤ Ref</li><li>➤ :</li><li>➤ Bailey 28 th Ed. Pg 256</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 1-day old baby is evaluated in the emergency department due to poor feeding, repeated bilious vomiting and not passing meconium since birth. Abdominal examination reveals a distended abdomen. Imaging shows the following picture. Identify the condition in this patient:", "options": [{"label": "A", "text": "Duodenal atresia", "correct": false}, {"label": "B", "text": "Anorectal malformation", "correct": false}, {"label": "C", "text": "Intusussception", "correct": false}, {"label": "D", "text": "Meconium ileus", "correct": true}], "correct_answer": "D. Meconium ileus", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/27/picture14.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. D) Meconium ileus</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A. Duodenal Atresia : Characterized by a \"double bubble\" sign on imaging , which represents a dilated stomach and duodenum with little to no gas beyond that point.</li><li>• Option A.</li><li>• Duodenal Atresia</li><li>• \"double bubble\"</li><li>• sign on imaging</li><li>• dilated stomach and duodenum</li><li>• Option B . Anorectal Malformation : Presents with failure to pass meconium and may have a distended abdomen , but the imaging would typically show an absence of the rectal passage and possibly a fistula.</li><li>• Option B</li><li>• Anorectal Malformation</li><li>• failure to pass meconium</li><li>• may have a distended abdomen</li><li>• Option C. Intussusception : A condition where a part of the intestine telescopes into an adjacent part , which could present with a target or doughnut sign on ultrasound. Intussusception would not typically present in a 1-day-old and is not indicated by the imaging. It seen in children in weaning period.</li><li>• Option C.</li><li>• Intussusception</li><li>• part of the intestine telescopes into an adjacent part</li><li>• present with a target or doughnut sign on ultrasound.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The imaging findings of a microcolon and signs of small bowel obstruction in a neonate with poor feeding , bilious vomiting , and failure to pass meconium indicate meconium ileus , a condition commonly associated with cystic fibrosis.</li><li>➤ imaging findings</li><li>➤ microcolon and signs of small bowel obstruction</li><li>➤ neonate with poor feeding</li><li>➤ bilious vomiting</li><li>➤ failure to pass meconium</li><li>➤ meconium ileus</li><li>➤ cystic fibrosis.</li><li>➤ An abdominal radiograph shows small bowel obstruction with a ground-glass appearance. Simple cases are managed with a water-soluble hyperosmolar contrast enema (diatrizoate) using fuoroscopy in a well-hydrated neonate. Complicated cases require a laparotomy and enterotomy for a luminal washout; a temporary stoma may be required. Postoperatively, N-acetylcysteine can be given by nasogastric tube and as enemas to loosen residual meconium. Genetic investigations look for defects in the cystic fibrosis transmembrane conductance regulator (CFTR) protein.</li><li>➤ An abdominal radiograph shows small bowel obstruction with a ground-glass appearance.</li><li>➤ Simple cases are managed with a water-soluble hyperosmolar contrast enema (diatrizoate) using fuoroscopy in a well-hydrated neonate.</li><li>➤ Complicated cases require a laparotomy and enterotomy for a luminal washout; a temporary stoma may be required. Postoperatively, N-acetylcysteine can be given by nasogastric tube and as enemas to loosen residual meconium.</li><li>➤ Genetic investigations look for defects in the cystic fibrosis transmembrane conductance regulator (CFTR) protein.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 289</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 289</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the condition seen in a child with symptoms of recurrent UTI and difficulty in voiding:", "options": [{"label": "A", "text": "Ureterocele", "correct": false}, {"label": "B", "text": "Posterior urethral valve", "correct": true}, {"label": "C", "text": "Vesico-ureteric reflux", "correct": false}, {"label": "D", "text": "Meatal stenosis", "correct": false}], "correct_answer": "B. Posterior urethral valve", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/27/picture16_VJXkWeT.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B) Posterior urethral valve</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Ureterocele : A cystic dilation of the lower end of the ureter that protrudes into the bladder . It can cause obstruction and lead to recurrent UTIs , but the classic imaging finding would be a \"cobra head\" sign on intravenous pyelogram (IVP), not typically seen on a voiding cystourethrogram (VCUG).</li><li>• Option A. Ureterocele</li><li>• cystic dilation</li><li>• lower end of the ureter that protrudes into the bladder</li><li>• obstruction and lead to recurrent UTIs</li><li>• classic imaging finding would be a \"cobra head\"</li><li>• Option C. Vesico-ureteric Reflux : A condition where urine flows backward from the bladder to the ureters and sometimes the kidneys , leading to recurrent UTIs . While it can be associated with difficulty voiding, it does not cause the changes in the urethra seen in the provided image.</li><li>• Option C.</li><li>• Vesico-ureteric Reflux</li><li>• urine flows backward from the bladder to the ureters and sometimes the kidneys</li><li>• recurrent UTIs</li><li>• Option D. Meatal Stenosis : A narrowing of the urethral opening , which can cause difficulty in voiding and may lead to UTIs . However, this condition would not cause the dilated posterior urethra seen on the provided imaging.</li><li>• Option D.</li><li>• Meatal Stenosis</li><li>• narrowing of the urethral opening</li><li>• cause difficulty in voiding and may lead to UTIs</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The imaging finding of a dilated posterior urethra in a child with recurrent UTI and difficulty in voiding is indicative of posterior urethral valves , a condition that requires early detection and treatment to prevent renal damage .</li><li>➤ dilated posterior urethra in a child with recurrent UTI</li><li>➤ difficulty in voiding</li><li>➤ posterior urethral valves</li><li>➤ early detection and treatment to prevent renal damage</li><li>➤ Posterior urethral valves are valves with membranes that have a small posterior slit within them. They typically lie just distal to the verumontanum and cause obstruction to the posterior urethra . They function as flap valves ; although they are obstructive to antegrade urinary flow, a urethral catheter can be passed retrogradely without any difficulty. Posterior urethral valves need to be detected and treated as early as possible to minimise the degree of renal failure. Investigations include a voiding cystourethrogram (VCUG), which shows a dilated posterior (prostatic) urethra Antenatal ultrasound shows a distended bladder, dilated prostatic urethra and hydroureteronephrosis. A “key-hole” appearance on USG is seen. Initial treatment is by catheterisation to drain the urine and decompress the bladder and upper urinary tracts. The valves themselves can be difficult to see on urethroscopy because the flow of irrigant sweeps them into the open position. Treatment is by endoscopic valve ablation after correction of renal function (if deranged) by catheterisation.</li><li>➤ Posterior urethral valves are valves with membranes that have a small posterior slit within them.</li><li>➤ Posterior urethral valves</li><li>➤ valves with membranes that have a small posterior slit</li><li>➤ They typically lie just distal to the verumontanum and cause obstruction to the posterior urethra .</li><li>➤ distal to the verumontanum</li><li>➤ cause obstruction to the posterior urethra</li><li>➤ They function as flap valves ; although they are obstructive to antegrade urinary flow, a urethral catheter can be passed retrogradely without any difficulty.</li><li>➤ They function as flap valves</li><li>➤ Posterior urethral valves need to be detected and treated as early as possible to minimise the degree of renal failure.</li><li>➤ Posterior urethral valves</li><li>➤ detected and treated as early as possible</li><li>➤ Investigations include a voiding cystourethrogram (VCUG), which shows a dilated posterior (prostatic) urethra</li><li>➤ Investigations</li><li>➤ voiding cystourethrogram</li><li>➤ Antenatal ultrasound shows a distended bladder, dilated prostatic urethra and hydroureteronephrosis. A “key-hole” appearance on USG is seen.</li><li>➤ Initial treatment is by catheterisation to drain the urine and decompress the bladder and upper urinary tracts. The valves themselves can be difficult to see on urethroscopy because the flow of irrigant sweeps them into the open position.</li><li>➤ Treatment is by endoscopic valve ablation after correction of renal function (if deranged) by catheterisation.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28th edition pg 1539</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28th edition pg 1539</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A Morgagni’s hernia is situated in which part of mediastinum?", "options": [{"label": "A", "text": "Anterior", "correct": true}, {"label": "B", "text": "Middle", "correct": false}, {"label": "C", "text": "Posterior", "correct": false}, {"label": "D", "text": "Superior", "correct": false}], "correct_answer": "A. Anterior", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/07/screenshot-2023-12-07-125149.jpg"], "explanation": "<p><strong>Ans. A) Anterior</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Morgagni's hernia is a type of diaphragmatic hernia that occurs in the anterior part of the mediastinum . It results from a congenital defect in the diaphragm , specifically through the foramina of Morgagni , which are small openings located near the sternum . These hernias are less common than the posterolateral Bochdalek hernias and typically contain omental fat , but can also contain portions of the liver, bowel, or other abdominal organs.</li><li>• Morgagni's hernia</li><li>• diaphragmatic hernia</li><li>• anterior part of the mediastinum</li><li>• congenital defect in the diaphragm</li><li>• foramina of Morgagni</li><li>• small openings located near the sternum</li><li>• hernias are less common than the posterolateral Bochdalek hernias</li><li>• omental fat</li><li>• contain portions of the liver, bowel, or other abdominal organs.</li><li>• The condition may be asymptomatic or present with respiratory or gastrointestinal symptoms due to the herniation of abdominal contents into the thoracic cavity . The diagnosis can often be made using imaging studies such as chest X-ray, CT scan, or MRI, which will show the presence of abdominal organs in the chest cavity, anterior to the heart.</li><li>• condition may be asymptomatic or present with respiratory or gastrointestinal symptoms</li><li>• herniation of abdominal contents into the thoracic cavity</li><li>• In the context of the mediastinum , Morgagni's hernia is located anteriorly, near where the diaphragm attaches to the sternum . This location is important to recognize for both diagnosis and surgical treatment . Repair of Morgagni's hernia is typically recommended to prevent complications such as bowel obstruction or strangulation and may be done via open surgery or laparoscopically.</li><li>• mediastinum</li><li>• Morgagni's hernia is located anteriorly, near where the diaphragm attaches to the sternum</li><li>• both diagnosis and surgical treatment</li><li>• Repair of Morgagni's hernia</li><li>• prevent complications such as bowel obstruction</li><li>• strangulation</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Ref : PG 271 Bailey 28 th ed</li><li>• Ref</li><li>• : PG 271 Bailey 28 th ed</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these statements is incorrect about necrotizing enterocolitis (NEC)?", "options": [{"label": "A", "text": "NEC is more common in breastfed babies", "correct": true}, {"label": "B", "text": "MC involved parts are colon and terminal ileum", "correct": false}, {"label": "C", "text": "Symptoms often include abdominal distension and rectal bleeding", "correct": false}, {"label": "D", "text": "Prominent radiological sign is pneumatosis intestinalis", "correct": false}], "correct_answer": "A. NEC is more common in breastfed babies", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/07/picture4_bTUmVZL.jpg"], "explanation": "<p><strong>Ans. A) NEC is more common in breastfed babies</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. MC involved parts are colon and terminal ileum : This is correct . NEC most commonly affects the terminal ileum and colon, although it can affect any part of the intestinal tract.</li><li>• Option B.</li><li>• MC involved parts are colon and terminal ileum</li><li>• correct</li><li>• Option C. Symptoms often include abdominal distension and rectal bleeding : This is also correct . NEC can present with a range of symptoms including feed intolerance, bilious vomiting, abdominal distension, and rectal bleeding.</li><li>• Option C.</li><li>• Symptoms often include abdominal distension and rectal bleeding</li><li>• correct</li><li>• Option D . Prominent radiological sign is pneumatosis intestinalis : This is correct . Pneumatosis intestinalis, which is the presence of gas within the wall of the intestines, is a hallmark radiological finding in NEC.</li><li>• Option D</li><li>• Prominent radiological sign is pneumatosis intestinalis</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The incorrect statement about necrotizing enterocolitis is that it is more common in breastfed babies ; in fact, NEC is more prevalent in formula-fed infants .</li><li>➤ incorrect statement</li><li>➤ necrotizing enterocolitis is that it is more common in breastfed babies</li><li>➤ NEC is more prevalent in formula-fed infants</li><li>➤ Treatment is gut rest, antibiotics and parenteral nutrition . Radiological signs include pneumatosis intestinalis, gas in the portal vein and if perforated, pneumoperitoneum. Surgery - bowel resection and anastomosis or a defunctioning stoma are options.</li><li>➤ Treatment is gut rest, antibiotics and parenteral nutrition .</li><li>➤ Treatment is gut rest, antibiotics and parenteral nutrition</li><li>➤ Radiological signs include pneumatosis intestinalis, gas in the portal vein and if perforated, pneumoperitoneum.</li><li>➤ Surgery - bowel resection and anastomosis or a defunctioning stoma are options.</li><li>➤ Surgery</li><li>➤ bowel resection and anastomosis</li><li>➤ defunctioning stoma</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 268</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 268</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 3-day-old neonate has respiratory distress, vomiting and cyanosis after every feeding. Examination reveals froth from nose. A diagnosis of trachea-esophageal fistula is suspected. Which of these is not commonly associated with congenital trachea-esophageal fistula?", "options": [{"label": "A", "text": "Ventricular septal defect", "correct": false}, {"label": "B", "text": "Ectopia vesicae", "correct": true}, {"label": "C", "text": "Hemi-vertebrae", "correct": false}, {"label": "D", "text": "Absent forearm bones", "correct": false}], "correct_answer": "B. Ectopia vesicae", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/07/picture5_HArn4Ev.jpg"], "explanation": "<p><strong>Ans. B) Ectopia vesicae</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A. Ventricular septal defect (VSD) is a Cardiac defect . Cardiac anomalies are commonly associated with TEF as part of the VACTERL association.</li><li>• Option A. Ventricular septal defect (VSD) is a Cardiac defect</li><li>• Cardiac anomalies</li><li>• associated with TEF</li><li>• Option C. Hemi-vertebrae represent Vertebral defects . Vertebral anomalies are most commonly associated with TEF , fitting within the VACTERL association.</li><li>• Option C. Hemi-vertebrae represent Vertebral defects</li><li>• most commonly associated with TEF</li><li>• Option D. Absent forearm bones – this falls under Limb abnormalities . Limb defects are a part of the VACTERL association and can be associated with TEF , although the specific absence of forearm bones is a more specific and less frequently observed anomaly.</li><li>• Option D. Absent forearm bones</li><li>• Limb abnormalities</li><li>• Limb defects</li><li>• part of the VACTERL association</li><li>• associated with TEF</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Insults acting during gastrulation may cause multiple anomalies , e.g. VACTERL syndrome (vertebral, anorectal, cardiac, tracheoesophageal, renal and limb anomalies) and CHARGE syndrome (coloboma, heart defects, choanal atresia, growth retardation, genital anomalies and ear anomalies). Anatomical variations in tracheoesophageal fistula with or without oesophageal atresia . In Type C, the upper pouch ends in the neck or upper chest but occasionally it reaches the fistula where muscle fibres are shared.</li><li>• Insults acting during gastrulation may cause multiple anomalies , e.g. VACTERL syndrome (vertebral, anorectal, cardiac, tracheoesophageal, renal and limb anomalies) and CHARGE syndrome (coloboma, heart defects, choanal atresia, growth retardation, genital anomalies and ear anomalies).</li><li>• Insults acting during gastrulation</li><li>• multiple anomalies</li><li>• Anatomical variations in tracheoesophageal fistula with or without oesophageal atresia . In Type C, the upper pouch ends in the neck or upper chest but occasionally it reaches the fistula where muscle fibres are shared.</li><li>• Anatomical variations in tracheoesophageal fistula with or without oesophageal atresia</li><li>• Diagnosis : A nasogastric tube coiled in the upper oesophageal pouch on a chest radiograph suggests the diagnosis. CT neck + thorax + abdomen will suggest the anatomy of fistula.</li><li>• Diagnosis</li><li>• Treatment : Surgical reconstruction</li><li>• Treatment</li><li>• Surgical reconstruction</li><li>• Ref : Bailey and Love’s short practice of surgery 28 th edition pg 263-66</li><li>• Ref</li><li>• :</li><li>• Bailey and Love’s short practice of surgery 28 th edition pg 263-66</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Most common cause of neonatal intestinal obstruction is:", "options": [{"label": "A", "text": "Intestinal atresia", "correct": true}, {"label": "B", "text": "Midgut malrotation", "correct": false}, {"label": "C", "text": "Meconium ileus", "correct": false}, {"label": "D", "text": "Hirschsprung disease", "correct": false}], "correct_answer": "A. Intestinal atresia", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Intestinal atresia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Opton B. Midgut Malrotation : This condition, where the intestines do not rotate correctly during fetal development, can lead to volvulus and obstruction . Although a significant cause of obstruction, it is less common than atresia.</li><li>• Opton B.</li><li>• Midgut Malrotation</li><li>• intestines do not rotate correctly during fetal development, can lead to volvulus and obstruction</li><li>• Option C. Meconium Ileus : It is particularly associated with cystic fibrosis and refers to obstruction of the ileum due to thickened, sticky meconium . It's a common cause but not as frequent as intestinal atresia.</li><li>• Option C.</li><li>• Meconium Ileus</li><li>• cystic fibrosis and refers to obstruction of the ileum due to thickened, sticky meconium</li><li>• Option D . Hirschsprung Disease : This is a condition caused by the absence of ganglion cells in the intestinal wall , leading to a functional obstruction . It is a common cause of obstruction but not the most common.</li><li>• Option D</li><li>• Hirschsprung Disease</li><li>• absence of ganglion cells in the intestinal wall</li><li>• functional obstruction</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most common cause of neonatal intestinal obstruction is intestinal atresia , with duodenal atresia being the most prevalent type within this category.</li><li>➤ most common cause of neonatal intestinal obstruction is intestinal atresia</li><li>➤ duodenal atresia</li><li>➤ most prevalent type</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1388</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1388</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the condition as shown in the X ray of a neonate below:", "options": [{"label": "A", "text": "Duodenal atresia", "correct": false}, {"label": "B", "text": "Jejunal atresia", "correct": true}, {"label": "C", "text": "Diaphragmatic hernia", "correct": false}, {"label": "D", "text": "Necrotizing enterocolitis", "correct": false}], "correct_answer": "B. Jejunal atresia", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/27/picture20.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B) Jejunal atresia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Duodenal Atresia : Typically presents with a \"double bubble\" sign on X-ray , indicating a blockage at the level of the duodenum with two dilated areas: the stomach and the proximal duodenum.</li><li>• Option A.</li><li>• Duodenal Atresia</li><li>• \"double bubble\" sign on X-ray</li><li>• Option C . Diaphragmatic Hernia : Would show abdominal contents within the thoracic cavity due to a defect in the diaphragm , which is not depicted in the X-ray shown.</li><li>• Option C</li><li>• Diaphragmatic Hernia</li><li>• abdominal contents within the thoracic cavity due to a defect in the diaphragm</li><li>• Option D. Necrotizing Enterocolitis : Typically presents with pneumatosis intestinalis (air within the bowel wall), which may be visible on X-ray , along with other signs of bowel compromise.</li><li>• Option D.</li><li>• Necrotizing Enterocolitis</li><li>• pneumatosis intestinalis</li><li>• visible on X-ray</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The \"triple bubble\" sign on an abdominal X-ray in a neonate is indicative of jejunal atresia , a condition characterized by a congenital obstruction in the jejunum , often due to a vascular incident during development.</li><li>➤ \"triple bubble\"</li><li>➤ abdominal X-ray in a neonate is indicative of jejunal atresia</li><li>➤ congenital obstruction in the jejunum</li><li>➤ vascular incident during development.</li><li>➤ Small bowel atresias may be isolated or multiple. If seen without other anomalies, they are thought to have been caused by localised vascular events occurring after organogenesis. A segmental ileal volvulus can cause an atresia ; thick meconium in cystic fibrosis is a risk factor. The upstream bowel dilates and becomes dysmotile , while the downstream bowel remains narrow; a primary anastomosis can accommodate up to a 5:1 discrepancy. Resection of the dilated portion is appropriate if this does not sacrifice too much intestine. There are four main types of jejunal/ileal atresia , ranging from an obstructing membrane (type 1) with continuity of the bowel wall through blind-ended segments of bowel separated by a fibrous cord (type 2) or V-shaped mesenteric defect (including the so-called apple-peel atresia - Type 3) to multiple atresias (‘string of sausages’- type 4).</li><li>➤ Small bowel atresias may be isolated or multiple. If seen without other anomalies, they are thought to have been caused by localised vascular events occurring after organogenesis.</li><li>➤ Small bowel atresias may be isolated or multiple.</li><li>➤ A segmental ileal volvulus can cause an atresia ; thick meconium in cystic fibrosis is a risk factor.</li><li>➤ segmental ileal volvulus can cause an atresia</li><li>➤ The upstream bowel dilates and becomes dysmotile , while the downstream bowel remains narrow; a primary anastomosis can accommodate up to a 5:1 discrepancy. Resection of the dilated portion is appropriate if this does not sacrifice too much intestine.</li><li>➤ upstream bowel dilates and becomes dysmotile</li><li>➤ There are four main types of jejunal/ileal atresia , ranging from an obstructing membrane (type 1) with continuity of the bowel wall through blind-ended segments of bowel separated by a fibrous cord (type 2) or V-shaped mesenteric defect (including the so-called apple-peel atresia - Type 3) to multiple atresias (‘string of sausages’- type 4).</li><li>➤ four main types of jejunal/ileal atresia</li><li>➤ obstructing membrane</li><li>➤ bowel separated by a fibrous cord</li><li>➤ apple-peel atresia</li><li>➤ multiple atresias</li><li>➤ Ref : Bailey 28 th Ed. Pg 1388</li><li>➤ Ref</li><li>➤ :</li><li>➤ Bailey 28 th Ed. Pg 1388</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "The aganglionic segment in Hirschsprung disease is found in which part of the colon:", "options": [{"label": "A", "text": "In whole colon", "correct": false}, {"label": "B", "text": "In the dilated segment of the colon", "correct": false}, {"label": "C", "text": "Proximal to dilated segment", "correct": false}, {"label": "D", "text": "Distal to dilated segment", "correct": true}], "correct_answer": "D. Distal to dilated segment", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Distal to dilated segment</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. In Whole Colon : This option refers to total colonic aganglionosis, a rare form of Hirschsprung disease affecting the entire colon . However, this is not the typical presentation.</li><li>• Option A.</li><li>• In Whole Colon</li><li>• total colonic aganglionosis,</li><li>• rare form of Hirschsprung disease affecting the entire colon</li><li>• Option B. In the Dilated Segment of the Colon : The dilated segment is actually the normal , ganglionated bowel , which becomes distended due to the obstruction caused by the downstream aganglionic segment.</li><li>• Option B.</li><li>• In the Dilated Segment of the Colon</li><li>• dilated segment is actually the normal</li><li>• ganglionated bowel</li><li>• distended due to the obstruction</li><li>• Option C . Proximal to Dilated Segment : The proximal to dilated segment is the normal bowel with intact ganglion cells . It is not the aganglionic segment but rather the part that reacts to the obstruction.</li><li>• Option C</li><li>• Proximal to Dilated Segment</li><li>• proximal to dilated segment is the normal bowel</li><li>• intact ganglion cells</li><li>• not the aganglionic segment</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In Hirschsprung disease ,</li><li>➤ Hirschsprung disease</li><li>➤ Normal bowel – proximal dilated portion</li><li>➤ Normal bowel</li><li>➤ proximal dilated portion</li><li>➤ Abnormal bowel – Distal constricted aganglionic bowel , usually rectum</li><li>➤ Abnormal bowel</li><li>➤ Distal constricted aganglionic bowel</li><li>➤ A transition zone lies between dilated proximal normal bowel and narrow , distal aganglionic bowel .</li><li>➤ transition zone lies between dilated proximal normal bowel and narrow</li><li>➤ distal aganglionic bowel</li><li>➤ IOC: Suction rectal biopsy to demonstrate aganglionosis</li><li>➤ Suction rectal biopsy to demonstrate aganglionosis</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 269</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 269</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 1 month old baby boy presents with progressive jaundice after birth. The baby is breastfed exclusively and has been feeding well. On examination, there is yellowish discoloration of skin, mildly distended abdomen, hepatomegaly. Technetium-99m iminodiacetic acid scan shows radionuclide that is concentrated in the liver but not excreted into the intestine. What is the treatment of choice in this patient?", "options": [{"label": "A", "text": "Duhamel surgery", "correct": false}, {"label": "B", "text": "Kasai procedure", "correct": true}, {"label": "C", "text": "Kimura surgery", "correct": false}, {"label": "D", "text": "Phototherapy", "correct": false}], "correct_answer": "B. Kasai procedure", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Kasai procedure</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A. Duhamel Surgery : This is a procedure typically used for the treatment of Hirschsprung's disease , not biliary atresia . It involves a pull-through operation where the normal ganglionated bowel is pulled down to the anus .</li><li>• Option A.</li><li>• Duhamel Surgery</li><li>• used for the treatment of Hirschsprung's disease</li><li>• biliary atresia</li><li>• pull-through operation</li><li>• normal ganglionated bowel is pulled down to the anus</li><li>• Option C. Kimura Surgery : This refers to duodenoduodenostomy , a surgical technique used to treat duodenal atresia , not biliary atresia.</li><li>• Option C.</li><li>• Kimura Surgery</li><li>• duodenoduodenostomy</li><li>• surgical technique used to treat duodenal atresia</li><li>• Option D. Phototherapy : This is not the treatment for biliary atresia , as the condition typically requires surgical intervention to prevent progressive liver damage and cirrhosis.</li><li>• Option D.</li><li>• Phototherapy</li><li>• not the treatment for biliary atresia</li><li>• requires surgical intervention</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ For a 1-month-old with biliary atresia indicated by persistent jaundice and a hepatobiliary scan showing no excretion of radionuclide into the intestine , the treatment of choice is the Kasai procedure , a hepatico-portoenterostomy to establish bile flow from the liver to the intestine .</li><li>➤ 1-month-old with biliary atresia</li><li>➤ persistent jaundice and a hepatobiliary scan showing no excretion of radionuclide into the intestine</li><li>➤ Kasai procedure</li><li>➤ hepatico-portoenterostomy</li><li>➤ bile flow from the liver to the intestine</li><li>➤ The Japanese and Anglo-Saxon classification describes three main types (Kasai)</li><li>➤ Japanese and Anglo-Saxon classification describes three main types</li><li>➤ Type I: atresia restricted to the CBD; Type II: atresia of the common hepatic duct: Type II a: a patent gallbladder and a patent CBD are present; Type II b: the gallbladder, cystic duct and CBD are also obliterated; Type III: atresia of the right and left hepatic ducts and the entire extrahepatic biliary tree.</li><li>➤ Type I: atresia restricted to the CBD;</li><li>➤ Type II: atresia of the common hepatic duct:</li><li>➤ Type II a: a patent gallbladder and a patent CBD are present;</li><li>➤ Type II b: the gallbladder, cystic duct and CBD are also obliterated;</li><li>➤ Type III: atresia of the right and left hepatic ducts and the entire extrahepatic biliary tree.</li><li>➤ Clinical : About one-third of patients are jaundiced at birth; in all affected babies, jaundice is present by the end of the first week and deepens progressively.</li><li>➤ Clinical</li><li>➤ The meconium may be a little bile-stained, but later the stools are pale and the urine is dark. Pruritus is severe. Clubbing and skin xanthomas, probably related to raised serum cholesterol, may be present</li><li>➤ The meconium may be a little bile-stained, but later the stools are pale and the urine is dark. Pruritus is severe.</li><li>➤ Clubbing and skin xanthomas, probably related to raised serum cholesterol, may be present</li><li>➤ Associations : Polysplenia, situs inversus, absent vena cava and preduodenal portal vein</li><li>➤ Associations</li><li>➤ Diagnosis :</li><li>➤ Diagnosis</li><li>➤ Fasting USG is the gold standard when biliary atresia is suspected. A shrunken gallbladder, a hyperechogenic liver hilum (‘triangular cord sign‘) or a cyst at the liver hilum without bile duct dilatation with associated anomalies support the diagnosis. Hepatobiliary scintigraphy may reveal the diagnosis but MRCP is highly sensitive and specific in the diagnosis. Inflammatory cells, a fibrotic liver parenchyma exhibiting signs of cholestasis and biliary neoductal structures establishes the definite diagnosis on liver biopsy.</li><li>➤ Fasting USG is the gold standard when biliary atresia is suspected. A shrunken gallbladder, a hyperechogenic liver hilum (‘triangular cord sign‘) or a cyst at the liver hilum without bile duct dilatation with associated anomalies support the diagnosis.</li><li>➤ Hepatobiliary scintigraphy may reveal the diagnosis but MRCP is highly sensitive and specific in the diagnosis.</li><li>➤ MRCP is highly sensitive and specific in the diagnosis.</li><li>➤ Inflammatory cells, a fibrotic liver parenchyma exhibiting signs of cholestasis and biliary neoductal structures establishes the definite diagnosis on liver biopsy.</li><li>➤ the definite diagnosis on liver biopsy.</li><li>➤ Treatment : The Kasai hepatico-portoenterostomy</li><li>➤ Treatment</li><li>➤ In the majority of cases in which the proximal hepatic ducts are either very small (type II) or atretic (type III) are treated by the Kasai procedure, in which radical excision of all bile duct tissue up to the liver capsule is performed. A Roux-en-Y loop of jejunum is anastomosed to the exposed area of liver capsule above the bifurcation of the portal vein, creating a portoenterostomy.</li><li>➤ Type I lesions. A direct Roux-en-Y hepaticojejunostomy</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1240-41</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1240-41</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these surgeries is performed for Meconium ileus?", "options": [{"label": "A", "text": "Duhamel surgery", "correct": false}, {"label": "B", "text": "Ramstedt procedure", "correct": false}, {"label": "C", "text": "Kimura surgery", "correct": false}, {"label": "D", "text": "Bishop-Koop procedure", "correct": true}], "correct_answer": "D. Bishop-Koop procedure", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Bishop-Koop procedure</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A . Duhamel Surgery : This procedure is performed for Hirschsprung disease and involves a pull-through technique where the normal ganglionated colon is brought down to the rectum while preserving a portion of the aganglionic rectum.</li><li>• Option</li><li>• A</li><li>• Duhamel Surgery</li><li>• performed for Hirschsprung disease and involves a pull-through technique</li><li>• Option B. Ramstedt Procedure : A surgical treatment for congenital hypertrophic pyloric stenosis , this procedure involves splitting the hypertrophied muscles of the pylorus to alleviate obstruction.</li><li>• Option B.</li><li>• Ramstedt Procedure</li><li>• surgical treatment for congenital hypertrophic pyloric stenosis</li><li>• Option C. Kimura Surgery : This is a technique used for the correction of duodenal atresia , typically involving a duodenoduodenostomy to bypass the atretic segment.</li><li>• Option C.</li><li>• Kimura Surgery</li><li>• technique used for the correction of duodenal atresia</li><li>• duodenoduodenostomy</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Bishop-Koop procedure is the surgical treatment for meconium ileus , involving a temporary ileostomy with a distal anastomosis to relieve intestinal obstruction caused by thickened meconium . However, it has been replaced currently by proximal enterotomy and removal of pellets . A trial of gastrograffin enema can be given prior to surgery to dissolve the pellets.</li><li>➤ Bishop-Koop procedure</li><li>➤ surgical treatment for meconium ileus</li><li>➤ temporary ileostomy</li><li>➤ distal anastomosis to relieve intestinal obstruction</li><li>➤ thickened meconium</li><li>➤ replaced currently by proximal enterotomy and removal of pellets</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 268, 1389</li><li>➤ Ref</li><li>➤ :</li><li>➤ Bailey and Love’s short practice of surgery 28 th edition pg 268, 1389</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A child is born with a mass over the lower back as shown in the picture below. His fetal alpha-protein levels are elevated. What is this mass most likely to be?", "options": [{"label": "A", "text": "Sacrococcygeal teratoma", "correct": true}, {"label": "B", "text": "Anterior sacral meningocoele", "correct": false}, {"label": "C", "text": "Overgrowth of coccyx", "correct": false}, {"label": "D", "text": "Gonadal tumor", "correct": false}], "correct_answer": "A. Sacrococcygeal teratoma", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/27/picture21.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. A) Sacrococcygeal teratoma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. Anterior Sacral Meningocele : A protrusion of the meninges through a defect in the vertebral bones , typically presenting as a sacral mass . However, it would not be associated with elevated alpha-fetoprotein levels.</li><li>• Option B.</li><li>• Anterior Sacral Meningocele</li><li>• protrusion of the meninges</li><li>• defect in the vertebral bones</li><li>• presenting as a sacral mass</li><li>• Option C. Overgrowth of Coccyx : This would refer to an abnormal elongation or enlargement of the coccyx , which is not typically associated with a palpable external mass or elevated alpha-fetoprotein levels.</li><li>• Option C.</li><li>• Overgrowth of Coccyx</li><li>• abnormal elongation or enlargement of the coccyx</li><li>• Option D. Gonadal Tumor : Tumors of gonadal origin in the sacrococcygeal area are rare and would not typically present as a mass in the lower back. Gonadal tumors would also not generally cause an elevation in alpha-fetoprotein unless they have yolk sac (endodermal sinus) elements.</li><li>• Option D.</li><li>• Gonadal Tumor</li><li>• origin in the sacrococcygeal area are rare</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The mass over the lower back in a newborn with elevated fetal alpha-protein levels is most likely a sacrococcygeal teratoma , a benign germ cell tumor that requires complete excision , including removal of the coccyx.</li><li>➤ mass over the lower back in a newborn with elevated fetal alpha-protein levels</li><li>➤ most likely a sacrococcygeal teratoma</li><li>➤ benign germ cell tumor</li><li>➤ complete excision</li><li>➤ These germ cell tumours arise from the coccyx and are usually diagnosed antenatally. They may have internal and external components or both. Most are benign mature teratomas, but some contain immature embryonic elements. Complete excision is usually achieved in the prone position and must include removing the coccyx and reconstruction of the pelvic floor. If the intra-abdominal component is large or vascular, the median sacral artery can be ligated through the abdomen. Bladder and bowel function are assessed following the pelvic floor repair. α-Fetoprotein levels are measured to detect recurrence.</li><li>➤ These germ cell tumours arise from the coccyx and are usually diagnosed antenatally. They may have internal and external components or both.</li><li>➤ Most are benign mature teratomas, but some contain immature embryonic elements.</li><li>➤ Complete excision is usually achieved in the prone position and must include removing the coccyx and reconstruction of the pelvic floor. If the intra-abdominal component is large or vascular, the median sacral artery can be ligated through the abdomen.</li><li>➤ Bladder and bowel function are assessed following the pelvic floor repair.</li><li>➤ α-Fetoprotein levels are measured to detect recurrence.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 272</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 272</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A mother brings her male infant to the paediatrician with right sided scrotal swelling, which is maximum at night, but disappears when the child wakes up in the morning. The swelling is soft and shows transillumination. What will be the management of this condition?", "options": [{"label": "A", "text": "Reassurance that this is self-limiting", "correct": false}, {"label": "B", "text": "Elective surgical repair", "correct": false}, {"label": "C", "text": "Wait for resolution till 6 months of age", "correct": false}, {"label": "D", "text": "Wait for resolution till 2 years of age", "correct": true}], "correct_answer": "D. Wait for resolution till 2 years of age", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Reassurance as this is self-limiting – Though this is the initial step, it is not the best answer . Some congenital hydroceles may resolve, while some may require surgical intervention.</li><li>• Option</li><li>• A. Reassurance as this is self-limiting</li><li>• initial step, it is not the best answer</li><li>• Option B. Elective surgical repair – Surgery is considered in cases where the hydrocele does not resolve on its own by a certain age or if it's causing complications. However, immediate surgical intervention is not typically indicated in a simple communicating hydrocele without complications.</li><li>• Option</li><li>• B. Elective surgical repair</li><li>• Surgery is considered in cases where the hydrocele does not resolve on its own by a certain age or if it's causing complications.</li><li>• Option C. Wait for resolution till 6 months – While some hydroceles may resolve within the first few months of life , it is more common to observe them for a longer period before considering surgery.</li><li>• Option</li><li>• C. Wait for resolution till 6 months</li><li>• hydroceles may resolve within the first few months of life</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Congenital hydroceles can be tense and uncomfortable, especially if over-examined, causing confusion with an incarcerated inguinal hernia .</li><li>• Congenital hydroceles</li><li>• tense and uncomfortable,</li><li>• over-examined, causing confusion with an incarcerated inguinal hernia</li><li>• Although hydroceles transilluminate, this is a flawed test for distinguishing one from an incarcerated inguinal hernia since light easily shines through an infant’s intestine.</li><li>• hydroceles transilluminate,</li><li>• flawed test</li><li>• Surgery is rarely indicated before 2 years because a majority resolve . The treatment is “herniotomy”.</li><li>• Surgery is rarely indicated before 2 years because a majority resolve</li><li>• Occasionally an encysted hydrocele of the cord (or hydrocele of the canal of Nuck in a girl) forms as the processus obliterates; persistence warrants exploration.</li><li>• Ref : Bailey and Lover 28 th Ed. Pg 257.</li><li>• Ref</li><li>• : Bailey and Lover 28 th Ed. Pg 257.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "What is the fluid of choice for correction of electrolyte deficiencies in infantile pyloric stenosis?", "options": [{"label": "A", "text": "Ringer’s lactate", "correct": false}, {"label": "B", "text": "Normal saline (0.9%)", "correct": false}, {"label": "C", "text": "Normal saline + KCl", "correct": false}, {"label": "D", "text": "DNS (5%) + KCl", "correct": true}], "correct_answer": "D. DNS (5%) + KCl", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) DNS (5%) + KCl</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Infantile pyloric stenosis is a condition that typically presents with projectile vomiting in young infants , leading to dehydration and electrolyte imbalances , most notably hypokalemic hypochloremic metabolic alkalosis . The correction of these electrolyte deficiencies is crucial in the management of this condition before any surgical intervention can be safely performed. The fluid used is 0.9% NS with 5%Dextrose with 0.15% Kcl.</li><li>• Infantile pyloric stenosis</li><li>• typically presents with projectile vomiting in young infants</li><li>• dehydration and electrolyte imbalances</li><li>• hypokalemic hypochloremic metabolic alkalosis</li><li>• The fluid used is 0.9% NS with 5%Dextrose with 0.15% Kcl.</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• If IHPS presentation is early , clinical findings are unremarkable; if late, weight loss and dehydration requiring resuscitation predominate.</li><li>• IHPS presentation is early</li><li>• weight loss and dehydration requiring resuscitation predominate.</li><li>• The diagnosis is made on a test feed or on abdominal ultrasound showing a thickened and lengthened pylorus. In a test feed, gastric peristalsis is seen passing from left to right across the abdomen, and in a relaxed (feeding) baby, the pyloric ‘tumour’ is palpable as an ‘olive’ in the right upper quadrant.</li><li>• Feeds are discontinued, and the stomach is emptied with an 8–10Fr nasogastric tube. Loss of gastric acid causes a hypochloraemic, hypokalaemic alkalosis and correction may take 24–48 hours; 0.9% saline with 0.15% KCl in 5% glucose given at 6–7.5 mL/kg/h provides maintenance and corrects deficits in most babies. As the chloride deficit is replaced, the kidneys correct the pH.</li><li>• Loss of gastric acid causes a hypochloraemic, hypokalaemic alkalosis and correction may take 24–48 hours; 0.9% saline with 0.15% KCl in 5% glucose given at 6–7.5 mL/kg/h provides maintenance and corrects deficits in most babies. As the chloride deficit is replaced, the kidneys correct the pH.</li><li>• Ref : Bailey 28 th Ed. Pg 259.</li><li>• Ref</li><li>• : Bailey 28 th Ed. Pg 259.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}]; if (!Array.isArray(questions) || questions.length === 0) { throw new Error("Questions data is empty or invalid"); } debugLog(`Successfully parsed ${questions.length} questions`); } catch (e) { console.error("Failed to parse questions_json:", e); document.getElementById('error-message').innerHTML = "Error loading quiz data. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('start-test').disabled = true; // Fallback to sample questions for testing questions = [ { text: "What is 2 + 2?", options: [ { label: "A", text: "3", correct: false }, { label: "B", text: "4", correct: true }, { label: "C", text: "5", correct: false }, { label: "D", text: "6", correct: false } ], correct_answer: "B. 4", question_images: [], explanation_images: [], explanation: "<p>2 + 2 = 4</p><p>@dams_new_robot</p>", bot: "@dams_new_robot", audio: "", video: "" } ]; debugLog("Loaded fallback questions"); } // Quiz state let currentQuestion = 0; let answers = new Array(questions.length).fill(null); let markedForReview = new Array(questions.length).fill(false); let timeRemaining = 30 * 60; // Duration in seconds let timerInterval = null; const quizId = `{title.replace(/\s+/g, '_').toLowerCase()}`; // Unique ID for local storage // Load saved progress function loadProgress() { try { debugLog("Loading progress from localStorage"); const saved = localStorage.getItem(`quiz_${quizId}`); if (saved) { const { savedAnswers, savedMarked, savedTime } = JSON.parse(saved); answers = savedAnswers || answers; markedForReview = savedMarked || markedForReview; timeRemaining = savedTime !== undefined ? savedTime : timeRemaining; debugLog("Progress loaded successfully"); } else { debugLog("No saved progress found"); } } catch (e) { console.error("Error loading progress:", e); debugLog("Failed to load progress: " + e.message); } } // Save progress function saveProgress() { try { debugLog("Saving progress to localStorage"); localStorage.setItem(`quiz_${quizId}`, JSON.stringify({ savedAnswers: answers, savedMarked: markedForReview, savedTime: timeRemaining })); debugLog("Progress saved successfully"); } catch (e) { console.error("Error saving progress:", e); debugLog("Failed to save progress: " + e.message); } } // Initialize quiz function initQuiz() { try { debugLog("Initializing quiz"); loadProgress(); const startButton = document.getElementById('start-test'); if (!startButton) { throw new Error("Start test button not found"); } startButton.addEventListener('click', startQuiz); debugLog("Start test button listener attached"); document.getElementById('previous-btn').addEventListener('click', showPreviousQuestion); document.getElementById('next-btn').addEventListener('click', showNextQuestion); document.getElementById('mark-review').addEventListener('click', toggleMarkForReview); document.getElementById('nav-toggle').addEventListener('click', toggleNavPanel); document.getElementById('submit-test').addEventListener('click', showSubmitModal); document.getElementById('continue-test').addEventListener('click', closeExitModal); document.getElementById('exit-test').addEventListener('click', () => { debugLog("Exiting test"); localStorage.removeItem(`quiz_${quizId}`); window.location.reload(); }); document.getElementById('cancel-submit').addEventListener('click', closeSubmitModal); document.getElementById('confirm-submit').addEventListener('click', submitTest); document.getElementById('take-again').addEventListener('click', () => { debugLog("Restarting test"); localStorage.removeItem(`quiz_${quizId}`); window.location.reload(); }); document.getElementById('review-test').addEventListener('click', () => showResults(currentResultQuestion)); document.getElementById('close-nav').addEventListener('click', toggleNavPanel); document.getElementById('theme-toggle').addEventListener('click', toggleTheme); document.getElementById('nav-filter').addEventListener('change', updateNavPanel); document.getElementById('prev-result').addEventListener('click', showPreviousResult); document.getElementById('next-result').addEventListener('click', showNextResult); document.getElementById('results-nav-toggle').addEventListener('click', toggleResultsNavPanel); document.getElementById('close-results-nav').addEventListener('click', toggleResultsNavPanel); document.getElementById('results-nav-filter').addEventListener('change', updateResultsNavPanel); debugLog("Quiz initialized successfully"); } catch (e) { console.error("Failed to initialize quiz:", e); debugLog("Failed to initialize quiz: " + e.message); document.getElementById('error-message').innerHTML = "Error initializing quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('start-test').disabled = true; } } // Start quiz function startQuiz() { try { debugLog("Starting quiz"); document.getElementById('instructions').classList.add('hidden'); document.getElementById('quiz').classList.remove('hidden'); showQuestion(currentQuestion); startTimer(); updateNavPanel(); debugLog("Quiz started successfully"); } catch (e) { console.error("Error starting quiz:", e); debugLog("Failed to start quiz: " + e.message); document.getElementById('error-message').innerHTML = "Error starting quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('quiz').classList.add('hidden'); document.getElementById('instructions').classList.remove('hidden'); } } // Show question function showQuestion(index) { try { debugLog(`Showing question ${index + 1}`); currentQuestion = index; const q = questions[index]; if (!q) { throw new Error(`Question ${index} is undefined`); } document.getElementById('question-number').innerHTML = `Question <span>${index + 1}</span> of ${questions.length}`; document.getElementById('question-text').innerHTML = q.text || "No question text available"; const imagesDiv = document.getElementById('question-images'); imagesDiv.innerHTML = q.question_images && q.question_images.length > 0 ? q.question_images.map(url => `<img src="${url}" alt="Question Image" class="max-w-full h-auto rounded-lg">`).join('') : ''; const optionsDiv = document.getElementById('options'); optionsDiv.innerHTML = q.options && q.options.length > 0 ? q.options.map(opt => ` <button class="option-btn w-full text-left p-3 border rounded-lg ${answers[index] === opt.label ? 'selected' : ''}" onclick="selectOption(${index}, '${opt.label}')" aria-label="Option ${opt.label}: ${opt.text}"> ${opt.label}. ${opt.text} </button> `).join('') : '<p class="text-red-500">No options available</p>'; document.getElementById('previous-btn').disabled = index === 0; document.getElementById('next-btn').disabled = index === questions.length - 1; document.getElementById('mark-review').classList.toggle('marked', markedForReview[index]); updateProgressBar(); saveProgress(); window.scrollTo({ top: 0, behavior: 'smooth' }); debugLog(`Question ${index + 1} displayed successfully`); } catch (e) { console.error("Error displaying question:", e); debugLog("Failed to display question: " + e.message); } } // Select option function selectOption(index, label) { try { debugLog(`Selecting option ${label} for question ${index + 1}`); answers[index] = label; const optionsDiv = document.getElementById('options'); const optionButtons = optionsDiv.querySelectorAll('.option-btn'); optionButtons.forEach(btn => { const btnLabel = btn.textContent.trim().split('.')[0]; btn.classList.toggle('selected', btnLabel === label); }); updateNavPanel(); saveProgress(); debugLog(`Option ${label} selected for question ${index + 1}`); } catch (e) { console.error("Error selecting option:", e); debugLog("Failed to select option: " + e.message); } } // Toggle mark for review function toggleMarkForReview() { try { debugLog(`Toggling mark for review on question ${currentQuestion + 1}`); markedForReview[currentQuestion] = !markedForReview[currentQuestion]; document.getElementById('mark-review').classList.toggle('marked', markedForReview[currentQuestion]); updateNavPanel(); saveProgress(); debugLog(`Mark for review toggled for question ${currentQuestion + 1}`); } catch (e) { console.error("Error marking for review:", e); debugLog("Failed to mark for review: " + e.message); } } // Navigate to previous question function showPreviousQuestion() { try { debugLog(`Navigating to previous question from ${currentQuestion + 1}`); if (currentQuestion > 0) { currentQuestion--; showQuestion(currentQuestion); } } catch (e) { console.error("Error navigating to previous question:", e); debugLog("Failed to navigate to previous question: " + e.message); } } // Navigate to next question function showNextQuestion() { try { debugLog(`Navigating to next question from ${currentQuestion + 1}`); if (currentQuestion < questions.length - 1) { currentQuestion++; showQuestion(currentQuestion); } } catch (e) { console.error("Error navigating to next question:", e); debugLog("Failed to navigate to next question: " + e.message); } } // Handle question navigation click function handleQuestionNavClick(index) { try { debugLog(`Navigating to question ${index + 1} via nav panel`); showQuestion(index); toggleNavPanel(); } catch (e) { console.error("Error handling navigation click:", e); debugLog("Failed to navigate via nav panel: " + e.message); } } // Start timer function startTimer() { try { debugLog("Starting timer"); timerInterval = setInterval(() => { if (timeRemaining <= 0) { debugLog("Timer expired, submitting test"); clearInterval(timerInterval); submitTest(); } else { timeRemaining--; const minutes = Math.floor(timeRemaining / 60); const seconds = timeRemaining % 60; document.getElementById('timer').innerHTML = `Time Remaining: <span>${minutes.toString().padStart(2, '0')}:${seconds.toString().padStart(2, '0')}</span>`; saveProgress(); } }, 1000); debugLog("Timer started successfully"); } catch (e) { console.error("Error starting timer:", e); debugLog("Failed to start timer: " + e.message); } } // Update progress bar function updateProgressBar() { try { debugLog("Updating progress bar"); const progress = ((currentQuestion + 1) / questions.length) * 100; document.getElementById('progress-bar').style.width = `${progress}%`; debugLog("Progress bar updated"); } catch (e) { console.error("Error updating progress bar:", e); debugLog("Failed to update progress bar: " + e.message); } } // Update quiz navigation panel function updateNavPanel() { try { debugLog("Updating quiz navigation panel"); const filter = document.getElementById('nav-filter').value; const navGrid = document.getElementById('nav-grid'); navGrid.innerHTML = questions.map((_, i) => { if (filter === 'answered' && !answers[i]) return ''; if (filter === 'unanswered' && answers[i]) return ''; if (filter === 'marked' && !markedForReview[i]) return ''; return ` <button class="question-nav-btn ${answers[i] ? 'answered' : 'unanswered'} ${markedForReview[i] ? 'marked-nav' : ''}" onclick="handleQuestionNavClick(${i})" aria-label="Go to Question ${i + 1}"> ${i + 1} </button> `; }).join(''); debugLog("Quiz navigation panel updated"); } catch (e) { console.error("Error updating quiz navigation panel:", e); debugLog("Failed to update quiz navigation panel: " + e.message); } } // Update results navigation panel function updateResultsNavPanel() { try { debugLog("Updating results navigation panel"); const filter = document.getElementById('results-nav-filter').value; const navGrid = document.getElementById('results-nav-grid'); navGrid.innerHTML = questions.map((_, i) => { if (filter === 'answered' && !answers[i]) return ''; if (filter === 'unanswered' && answers[i]) return ''; if (filter === 'marked' && !markedForReview[i]) return ''; return ` <button class="result-nav-btn-grid ${answers[i] ? 'answered' : 'unanswered'} ${markedForReview[i] ? 'marked-nav' : ''}" onclick="handleResultNavClick(${i})" aria-label="Go to Result for Question ${i + 1}"> ${i + 1} </button> `; }).join(''); debugLog("Results navigation panel updated"); } catch (e) { console.error("Error updating results navigation panel:", e); debugLog("Failed to update results navigation panel: " + e.message); } } // Toggle quiz navigation panel function toggleNavPanel() { try { debugLog("Toggling quiz navigation panel"); const navPanel = document.getElementById('nav-panel'); navPanel.classList.toggle('hidden'); debugLog("Quiz navigation panel toggled"); } catch (e) { console.error("Error toggling quiz navigation panel:", e); debugLog("Failed to toggle quiz navigation panel: " + e.message); } } // Toggle results navigation panel function toggleResultsNavPanel() { try { debugLog("Toggling results navigation panel"); const resultsNavPanel = document.getElementById('results-nav-panel'); resultsNavPanel.classList.toggle('hidden'); if (!resultsNavPanel.classList.contains('hidden')) { updateResultsNavPanel(); } debugLog("Results navigation panel toggled"); } catch (e) { console.error("Error toggling results navigation panel:", e); debugLog("Failed to toggle results navigation panel: " + e.message); } } // Handle result navigation click function handleResultNavClick(index) { try { debugLog(`Navigating to result for question ${index + 1} via nav panel`); showResults(index); toggleResultsNavPanel(); } catch (e) { console.error("Error handling result navigation click:", e); debugLog("Failed to navigate to result: " + e.message); } } // Show submit modal function showSubmitModal() { try { debugLog("Showing submit modal"); const attempted = answers.filter(a => a !== null).length; document.getElementById('attempted-count').textContent = attempted; document.getElementById('unattempted-count').textContent = questions.length - attempted; document.getElementById('submit-modal').classList.remove('hidden'); debugLog("Submit modal displayed"); } catch (e) { console.error("Error showing submit modal:", e); debugLog("Failed to show submit modal: " + e.message); } } // Close submit modal function closeSubmitModal() { try { debugLog("Closing submit modal"); document.getElementById('submit-modal').classList.add('hidden'); debugLog("Submit modal closed"); } catch (e) { console.error("Error closing submit modal:", e); debugLog("Failed to close submit modal: " + e.message); } } // Close exit modal function closeExitModal() { try { debugLog("Closing exit modal"); document.getElementById('exit-modal').classList.add('hidden'); debugLog("Exit modal closed"); } catch (e) { console.error("Error closing exit modal:", e); debugLog("Failed to close exit modal: " + e.message); } } // Submit test function submitTest() { try { debugLog("Submitting test"); clearInterval(timerInterval); document.getElementById('quiz').classList.add('hidden'); document.getElementById('submit-modal').classList.add('hidden'); document.getElementById('results').classList.remove('hidden'); showResults(0); // Start with first question // Trigger confetti animation confetti({ particleCount: 100, spread: 70, origin: { y: 0.6 } }); localStorage.removeItem(`quiz_${quizId}`); debugLog("Test submitted successfully"); } catch (e) { console.error("Error submitting test:", e); debugLog("Failed to submit test: " + e.message); } } // Show result for a single question function showResults(index) { try { debugLog(`Showing result for question ${index + 1}`); currentResultQuestion = index; let correct = 0, wrong = 0, unanswered = 0, marked = 0; answers.forEach((answer, i) => { const isCorrect = answer && questions[i].options.find(opt => opt.label === answer)?.correct; if (answer === null) unanswered++; else if (isCorrect) correct++; else wrong++; if (markedForReview[i]) marked++; }); const q = questions[index]; if (!q) { throw new Error(`Question ${index} is undefined`); } const userAnswer = answers[index]; const isCorrect = userAnswer && q.options.find(opt => opt.label === userAnswer)?.correct; const resultsContent = document.getElementById('results-content'); resultsContent.innerHTML = ` <div class="border p-4 rounded-lg ${isCorrect ? 'bg-green-50' : userAnswer ? 'bg-red-50' : 'bg-gray-50'}"> <p class="font-semibold">Question ${index + 1}: ${q.text || 'No question text'}</p> ${q.question_images && q.question_images.length > 0 ? q.question_images.map(url => `<img src="${url}" alt="Question Image" class="max-w-full h-auto rounded-lg my-2">`).join('') : ''} <p><strong>Your Answer:</strong> ${userAnswer ? `${userAnswer}. ${q.options.find(opt => opt.label === userAnswer)?.text || 'Invalid option'}` : 'Unanswered'}</p> <p><strong>Correct Answer:</strong> ${q.correct_answer || 'Unknown'}</p> <div class="mt-2">${q.explanation || 'No explanation available'}</div> ${q.explanation_images && q.explanation_images.length > 0 ? q.explanation_images.map(url => `<img src="${url}" alt="Explanation Image" class="max-w-full h-auto rounded-lg my-2">`).join('') : ''} ${q.video ? ` <button class="play-video bg-blue-500 text-white px-4 py-2 rounded-lg mt-2" onclick="loadVideo(this, '${q.video}', 'video-${index}')" aria-label="Play explanation video for Question ${index + 1}"> Play Video Explanation </button> <div id="video-${index}" class="video-container mt-2"></div> ` : '<p class="text-gray-500 mt-2">No video available</p>'} ${q.audio ? ` <button class="play-audio bg-blue-500 text-white px-4 py-2 rounded-lg mt-2" onclick="loadAudio(this, '${q.audio}', 'audio-${index}')" aria-label="Play audio explanation for Question ${index + 1}"> Play Audio Explanation </button> <div id="audio-${index}" class="audio-container mt-2"></div> ` : ''} </div> `; document.getElementById('correct-count').textContent = correct; document.getElementById('wrong-count').textContent = wrong; document.getElementById('unanswered-count').textContent = unanswered; document.getElementById('marked-count').textContent = marked; document.getElementById('result-question-number').innerHTML = `Question <span>${index + 1}</span> of ${questions.length}`; document.getElementById('prev-result').disabled = index === 0; document.getElementById('next-result').disabled = index === questions.length - 1; updateResultsNavPanel(); window.scrollTo({ top: 0, behavior: 'smooth' }); debugLog(`Result for question ${index + 1} displayed successfully`); } catch (e) { console.error("Error displaying result:", e); debugLog("Failed to display result: " + e.message); } } // Navigate to previous result function showPreviousResult() { try { debugLog(`Navigating to previous result from question ${currentResultQuestion + 1}`); if (currentResultQuestion > 0) { showResults(currentResultQuestion - 1); } } catch (e) { console.error("Error navigating to previous result:", e); debugLog("Failed to navigate to previous result: " + e.message); } } // Navigate to next result function showNextResult() { try { debugLog(`Navigating to next result from question ${currentResultQuestion + 1}`); if (currentResultQuestion < questions.length - 1) { showResults(currentResultQuestion + 1); } } catch (e) { console.error("Error navigating to next result:", e); debugLog("Failed to navigate to next result: " + e.message); } } // Lazy-load video function loadVideo(button, videoUrl, containerId) { try { debugLog(`Loading video for ${containerId}: ${videoUrl}`); if (!videoUrl) { const container = document.getElementById(containerId); container.innerHTML = `<p class="text-gray-500">No video available</p>`; button.remove(); debugLog("No video URL provided"); return; } const container = document.getElementById(containerId); container.innerHTML = ` <div class="video-loading"></div> <video controls class="w-full max-w-[600px] rounded-lg" preload="metadata" aria-label="Video explanation"> <source src="${videoUrl}" type="${videoUrl.endsWith('.m3u8') ? 'application/x-mpegURL' : 'video/mp4'}"> Your browser does not support the video tag. </video> `; container.classList.add('active'); button.remove(); // Initialize HLS.js for .m3u8 videos const video = container.querySelector('video'); if (videoUrl.endsWith('.m3u8') && Hls.isSupported()) { const hls = new Hls(); hls.loadSource(videoUrl); hls.attachMedia(video); hls.on(Hls.Events.ERROR, (event, data) => { console.error("HLS.js error:", data); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; debugLog("HLS.js error: " + JSON.stringify(data)); }); } else if (videoUrl.endsWith('.m3u8') && video.canPlayType('application/vnd.apple.mpegurl')) { video.src = videoUrl; } // Handle video load errors video.onerror = () => { console.error("Video load error for URL:", videoUrl); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; debugLog("Video load error for URL: " + videoUrl); }; // Remove loading spinner when video is ready video.onloadedmetadata = () => { container.querySelector('.video-loading').remove(); debugLog("Video loaded successfully"); }; } catch (e) { console.error("Error loading video:", e); debugLog("Failed to load video: " + e.message); const container = document.getElementById(containerId); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; } } // Lazy-load audio function loadAudio(button, audioUrl, containerId) { try { debugLog(`Loading audio for ${containerId}: ${audioUrl}`); if (!audioUrl) { const container = document.getElementById(containerId); container.innerHTML = `<p class="text-gray-500">No audio available</p>`; button.remove(); debugLog("No audio URL provided"); return; } const container = document.getElementById(containerId); container.innerHTML = ` <audio controls class="w-full max-w-[600px]" preload="metadata" aria-label="Audio explanation"> <source src="${audioUrl}" type="audio/mpeg"> Your browser does not support the audio tag. </audio> `; container.classList.add('active'); button.remove(); // Handle audio load errors const audio = container.querySelector('audio'); audio.onerror = () => { console.error("Audio load error for URL:", audioUrl); container.innerHTML = `<p class="text-red-500">Error loading audio. <a href="${audioUrl}" target="_blank" aria-label="Open audio in new tab">Open audio</a></p>`; debugLog("Audio load error for URL: " + audioUrl); }; debugLog("Audio loaded successfully"); } catch (e) { console.error("Error loading audio:", e); debugLog("Failed to load audio: " + e.message); const container = document.getElementById(containerId); container.innerHTML = `<p class="text-red-500">Error loading audio. <a href="${audioUrl}" target="_blank" aria-label="Open audio in new tab">Open audio</a></p>`; } } // Toggle dark mode function toggleTheme() { try { debugLog("Toggling theme"); document.documentElement.classList.toggle('dark'); localStorage.setItem('theme', document.documentElement.classList.contains('dark') ? 'dark' : 'light'); debugLog("Theme toggled successfully"); } catch (e) { console.error("Error toggling theme:", e); debugLog("Failed to toggle theme: " + e.message); } } // Load theme preference function loadTheme() { try { debugLog("Loading theme preference"); const theme = localStorage.getItem('theme'); if (theme === 'dark') { document.documentElement.classList.add('dark'); } debugLog("Theme loaded successfully"); } catch (e) { console.error("Error loading theme:", e); debugLog("Failed to load theme: " + e.message); } } // Initialize on DOM content loaded window.addEventListener('DOMContentLoaded', () => { try { debugLog("DOM content loaded, initializing quiz"); loadTheme(); initQuiz(); } catch (e) { console.error("Error during DOMContentLoaded:", e); debugLog("Failed to initialize on DOMContentLoaded: " + e.message); document.getElementById('error-message').innerHTML = "Error initializing quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); } }); </script> </body> </html>" frameborder="0" width="100%" height="2000px">
<div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <h2 class="text-xl font-semibold mb-4">Instructions</h2> <h4 class="text-gray-800 text-lg font-semibold mt-6 mb-4">Test Features:</h4> <ul class="space-y-3"> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Multiple choice questions with single correct answers </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Timer-based testing for realistic exam conditions </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Mark questions for review functionality </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Comprehensive results and performance analysis </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Mobile-optimized interface for learning on-the-go </li> </ul> <div class="mt-6 flex space-x-4 button-group md:flex-row flex-col"> <button class="bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="start-test">Start Test</button> </div> <div class="error-message hidden" id="error-message"></div> </div> </section> <!-- Quiz Section --> <section class="container mx-auto px-4 md:px-6 pt-4 md:pt-6 pb-1 hidden section-transition" id="quiz"> <div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <!-- Progress Bar --> <div class="w-full bg-gray-200 rounded-full h-3 mb-4"> <div class="progress-bar h-3 rounded-full" id="progress-bar" style="width: 0%"></div> </div> <!-- Question Header --> <div class="flex flex-col md:flex-row justify-between items-center mb-4"> <h2 class="text-lg font-semibold" id="question-number">Question <span>1</span> of 4</h2> <p class="text-lg font-semibold mt-2 md:mt-0" id="timer">Time Remaining: <span>00:00</span></p> </div> <!-- Question Content --> <div class="mb-6" id="question-content"> <p class="text-gray-800 mb-4" id="question-text"></p> <div class="flex flex-wrap gap-4 mb-4" id="question-images"></div> <div class="space-y-3" id="options"></div> </div> <!-- Navigation Buttons --> <div class="flex flex-col md:flex-row justify-between items-center gap-2 md:gap-4"> <div class="flex gap-2 w-full md:w-auto"> <button class="bg-[#2c5281] text-white px-4 py-3 w-full md:w-32 h-14 rounded-lg hover:bg-[#2c5281] transition" disabled="" id="previous-btn">Previous</button> <button class="bg-[#2c5281] text-white px-4 py-3 w-full md:w-32 h-14 rounded-lg hover:bg-[#2c5281] transition" id="next-btn">Next</button> </div> <div class="flex items-center gap-2"> <button class="bg-transparent text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-100 transition flex items-center gap-1" id="mark-review"> Review <svg xmlns="http://www.w3.org/2000/svg" class="h-5 w-5" viewBox="0 0 20 20" fill="currentColor"> <path d="M10 2a1 1 0 00-1 1v14l3.293-3.293a1 1 0 011.414 0L17 17V3a1 1 0 00-1-1H10z" /> </svg> </button> <button class="bg-transparent text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-100 transition flex items-center gap-1" id="nav-toggle"> Question 🧭 </button> <button class="bg-green-500 text-white px-6 py-3 w-44 h-14 rounded-lg hover:bg-green-600 transition w-full md:w-auto" id="submit-test">Submit Test</button> </div> </div> </section> <!-- Results Section --> <section class="container mx-auto px-4 md:px-6 pt-4 md:pt-6 pb-1 hidden section-transition" id="results"> <div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <h2 class="text-2xl font-semibold mb-4">Anaesthesia Machine - Results</h2> <div class="grid grid-cols-1 md:grid-cols-2 gap-4 mb-6"> <p><strong>Correct:</strong> <span id="correct-count" class="text-[#000000]">0</span></p> <p><strong>Wrong:</strong> <span id="wrong-count" class="text-[#000000]">0</span></p> <p><strong>Unanswered:</strong> <span id="unanswered-count" class="text-[#000000]-500">0</span></p> <p><strong>Marked for Review:</strong> <span id="marked-count" class="text-[#000000]">0</span></p> </div> <h3 class="text-lg font-semibold mb-4" id="result-question-number">Question <span>1</span> of 4</h3> <div class="space-y-6" id="results-content"></div> <div class="result-nav"> <button aria-label="Previous question result" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" disabled="" id="prev-result">Previous</button> <button aria-label="Toggle results navigation panel" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="results-nav-toggle">Result 🧭</button> <button aria-label="Next question result" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="next-result">Next</button> </div> <div class="mt-6 flex space-x-4 button-group md:flex-row flex-col"> <button class="bg-green-500 text-white px-6 py-2 rounded-lg hover:bg-green-600 transition" id="take-again">Take Again</button> </div> </div> </section> <!-- Exit Confirmation Modal --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 hidden" id="exit-modal" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white rounded-lg p-6 max-w-sm w-full"> <h2 class="text-xl font-semibold mb-4">Leave Test?</h2> <p class="text-gray-700 mb-4">Your progress will be lost if you leave this page. Are you sure you want to exit?</p> <div class="flex justify-end space-x-4"> <button class="bg-gray-300 text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-400 transition" id="continue-test">No, Continue</button> <button class="bg-red-500 text-white px-4 py-2 rounded-lg hover:bg-red-600 transition" id="exit-test">Yes, Exit</button> </div> </div> </div> <!-- Submit Confirmation Modal --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 hidden" id="submit-modal" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white rounded-lg p-6 max-w-sm w-full"> <h2 class="text-xl font-semibold mb-4">Confirm Submission</h2> <p class="text-gray-700 mb-2">You have attempted <span id="attempted-count">0</span> of 4 questions.</p> <p class="text-gray-700 mb-4"><span id="unattempted-count">0</span> questions are unattempted.</p> <div class="flex justify-end space-x-4"> <button class="bg-gray-300 text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-400 transition" id="cancel-submit">Cancel</button> <button class="text-white px-4 py-2 rounded-lg hover:bg-[#1a365d] transition" style="background-color: #2c5281;" id="confirm-submit">Submit Test</button> </div> </div> </div> <!-- Quiz Navigation Panel --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 z-50 nav-panel hidden overflow-y-auto" id="nav-panel" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white shadow-lg p-4 rounded-lg w-full max-w-2xl max-h-[80vh] overflow-y-auto"> <h2 class="text-lg font-semibold mb-4">Questions Navigation</h2> <div class="mb-4"> <select class="w-full p-2 border rounded-lg text-gray-700" id="nav-filter"> <option value="all">All Questions</option> <option value="answered">Answered</option> <option value="unanswered">Unanswered</option> <option value="marked">Marked for Review</option> </select> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-nav">Close</button> </div> </div> <!-- Results Navigation Panel --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 z-50 results-nav-panel hidden overflow-y-auto" id="results-nav-panel" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white shadow-lg p-4 rounded-lg w-full max-w-2xl max-h-[80vh] overflow-y-auto"> <h2 class="text-lg font-semibold mb-4">Results Navigation</h2> <div class="mb-4"> <select class="w-full p-2 border rounded-lg text-gray-700" id="results-nav-filter"> <option value="all">All Questions</option> <option value="answered">Answered</option> <option value="unanswered">Unanswered</option> <option value="marked">Marked for Review</option> </select> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="results-nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-results-nav">Close</button> </div> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="results-nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-results-nav">Close</button> </div> <!-- JavaScript Logic --> <script> // Enable debug mode for detailed logging const DEBUG_MODE = true; // Log debug messages function debugLog(message) { if (DEBUG_MODE) { console.log(`[DEBUG] ${message}`); } } // Initialize questions with error handling let questions = []; let currentResultQuestion = 0; // State for current question in results try { debugLog("Attempting to parse questions_json"); questions = [{"text": "Identify the type of covering used for burns wound shown in the image:", "options": [{"label": "A", "text": "Free flap", "correct": false}, {"label": "B", "text": "Full thickness graft", "correct": false}, {"label": "C", "text": "Thiersch graft", "correct": true}, {"label": "D", "text": "Composite graft", "correct": false}], "correct_answer": "C. Thiersch graft", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/11/picture1_8qNKeTg.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Thiersch graft</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A . Free Flap : A free flap is a type of graft that involves the transfer of tissue , including skin, muscle, fat, or a combination thereof, where vascular anastomosis is done at recipient site .</li><li>• Option A</li><li>• Free Flap</li><li>• free flap is a type of graft that involves the transfer of tissue</li><li>• skin, muscle, fat,</li><li>• vascular anastomosis is done at recipient site</li><li>• Option B . Full Thickness Graft : A full-thickness skin graft consists of the epidermis and the entire dermis . It is taken from donor sites that can be closed directly and is not meshed.</li><li>• Option B</li><li>• Full Thickness Graft</li><li>• epidermis and the entire dermis</li><li>• Option D . Composite graft: It’s a type of full thickness skin graft with additional tissue like fat or cartilage.</li><li>• Option D</li><li>• Composite graft:</li><li>• type of full thickness skin graft</li><li>• fat or cartilage.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ The Thiersch graft , a split-thickness skin graft , involves the transplantation of epidermis and part of the dermis from a donor site to a wound , commonly used for large burn injuries due to its ability to cover extensive areas and facilitate wound healing.</li><li>➤ Thiersch graft</li><li>➤ split-thickness skin graft</li><li>➤ transplantation of epidermis and part of the dermis from a donor site to a wound</li><li>➤ large burn injuries due to its ability to cover extensive areas</li><li>➤ Split thickness skin graft:</li><li>➤ Split thickness skin graft:</li><li>➤ Split-thickness skin grafts consist of epidermis and a variable amount of dermis and are sometimes referred to as Thiersch grafts . They are commonly harvested from the thigh using a dermatome or graft knife to achieve a consistent depth. It is relatively simple to harvest large areas of skin to reconstruct sizeable defects such as those following a significant burn injury. They are not very cosmetic, as graft undergoes secondary contracture. The grafted skin can then be meshed or fenestrated to expand and cover a wider surface area as well as avoid the accumulation of an underlying haematoma. The graft is typically sutured, glued or stapled to the recipient site</li><li>➤ Split-thickness skin grafts consist of epidermis and a variable amount of dermis and are sometimes referred to as Thiersch grafts .</li><li>➤ Split-thickness skin grafts</li><li>➤ epidermis</li><li>➤ variable amount of dermis</li><li>➤ Thiersch grafts</li><li>➤ They are commonly harvested from the thigh using a dermatome or graft knife to achieve a consistent depth.</li><li>➤ It is relatively simple to harvest large areas of skin to reconstruct sizeable defects such as those following a significant burn injury.</li><li>➤ They are not very cosmetic, as graft undergoes secondary contracture.</li><li>➤ The grafted skin can then be meshed or fenestrated to expand and cover a wider surface area as well as avoid the accumulation of an underlying haematoma.</li><li>➤ The graft is typically sutured, glued or stapled to the recipient site</li><li>➤ Ref : Bailey 28 th Ed. PG 686-87</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. PG 686-87</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify this instrument used for treatment of Burns wounds:", "options": [{"label": "A", "text": "Powered dermatome", "correct": false}, {"label": "B", "text": "Humby’s knife", "correct": true}, {"label": "C", "text": "Skin graft mesher", "correct": false}, {"label": "D", "text": "Thiersch knife", "correct": false}], "correct_answer": "B. Humby’s knife", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/21/screenshot-2024-03-21-173549.png"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/21/screenshot-2024-03-21-173634.png", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/21/screenshot-2024-03-21-173642.png", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/21/screenshot-2024-03-21-173650.png"], "explanation": "<p><strong>Ans. B) Humby’s knife</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Split-thickness skin grafts are taken with either hand-held or powered skin knives . The most used donor site is the thigh , with the buttock preferable in children and cosmetically sensitive individuals . Humby’s knife is a manual instrument for harvesting split-thickness skin grafts , commonly utilized in burn wound management to obtain skin from donor sites like the thigh. Appropriate thickness of graft as assessed by appearance of punctate skin hemorrhages at donor site. If subcutaneous fat is noticed, the graft is too thick.</li><li>➤ Split-thickness skin grafts are taken with either hand-held or powered skin knives .</li><li>➤ Split-thickness skin grafts</li><li>➤ hand-held or powered skin knives</li><li>➤ The most used donor site is the thigh , with the buttock preferable in children and cosmetically sensitive individuals .</li><li>➤ used donor site is the thigh</li><li>➤ buttock</li><li>➤ children and cosmetically sensitive individuals</li><li>➤ Humby’s knife is a manual instrument for harvesting split-thickness skin grafts , commonly utilized in burn wound management to obtain skin from donor sites like the thigh.</li><li>➤ Humby’s knife</li><li>➤ manual instrument for harvesting split-thickness skin grafts</li><li>➤ Appropriate thickness of graft as assessed by appearance of punctate skin hemorrhages at donor site. If subcutaneous fat is noticed, the graft is too thick.</li><li>➤ Powered dermatome:</li><li>➤ Powered dermatome:</li><li>➤ Skin graft Mesher:</li><li>➤ Skin graft Mesher:</li><li>➤ Thiersch knife:</li><li>➤ Thiersch knife:</li><li>➤ Ref : Bailey 27 th edition Pg 639</li><li>➤ Ref</li><li>➤ : Bailey 27 th edition Pg 639</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the material attached to the burns wound in the picture below:", "options": [{"label": "A", "text": "Biobrane", "correct": true}, {"label": "B", "text": "Amniotic graft", "correct": false}, {"label": "C", "text": "Hydrocolloid dressings (Duoderm)", "correct": false}, {"label": "D", "text": "Vaseline impregnated gauze", "correct": false}], "correct_answer": "A. Biobrane", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/11/picture8.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/11/picture9.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/11/picture10.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/11/picture11.jpg"], "explanation": "<p><strong>Ans. A) Biobrane</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. Amniotic Graft: Amniotic grafts are derived from the amniotic membrane part of the placenta . They are used in burn care and wound management for their natural therapeutic properties , which include anti-inflammatory factors and growth-promoting effects . These grafts can reduce scar formation, pain, and healing time.</li><li>• Option B. Amniotic Graft:</li><li>• derived from the amniotic membrane part of the placenta</li><li>• burn care and wound management for their natural therapeutic properties</li><li>• anti-inflammatory factors and growth-promoting effects</li><li>• Option C. Hydrocolloid Dressings (Duoderm):</li><li>• Option C. Hydrocolloid Dressings (Duoderm):</li><li>• Hydrocolloid dressings like Duoderm are made of gel-forming agents like pectin or gelatin . They provide a moist and insulated healing environment, which can help in the management of light to moderately exuding wounds . These dressings are self-adhesive and can conform to the wound site, but they need to be changed every few days.</li><li>• Duoderm are made of gel-forming agents like pectin or gelatin</li><li>• moist and insulated healing environment,</li><li>• help in the management of light to moderately exuding wounds</li><li>• Option D. Vaseline Impregnated Gauze: This type of dressing consists of gauze that has been saturated with petrolatum (Vaseline). It is non-adherent, which makes it a good choice for wounds with fragile skin where the dressing needs to be changed without causing trauma. It helps keep the wound moist and protected from outside contaminants.</li><li>• Option D. Vaseline Impregnated Gauze:</li><li>• dressing consists of gauze that has been saturated with petrolatum</li><li>• non-adherent,</li><li>• good choice for wounds with fragile skin</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Hydrocolloid dressings need to be changed every 3–5 days. They also provide a moist environment, which is good for epithelialization. Biosynthetic dressings (e.g., Bio brane®) and natural (e.g., amniotic membranes) dressings also provide good healing environments and do not need to be changed. They are ideal for one-stop management of superficial burns, being easy to apply and comfortable. However, they will become detached if applied to deep dermal wounds as the eschar needs to separate. They are therefore not as useful in mixed-depth wounds.</li><li>• Hydrocolloid dressings need to be changed every 3–5 days. They also provide a moist environment, which is good for epithelialization.</li><li>• Hydrocolloid dressings need to be changed every 3–5 days.</li><li>• Biosynthetic dressings (e.g., Bio brane®) and natural (e.g., amniotic membranes) dressings also provide good healing environments and do not need to be changed. They are ideal for one-stop management of superficial burns, being easy to apply and comfortable. However, they will become detached if applied to deep dermal wounds as the eschar needs to separate. They are therefore not as useful in mixed-depth wounds.</li><li>• Biosynthetic dressings</li><li>• natural</li><li>• dressings also provide good healing environments and do not need to be changed.</li><li>• Ref : Bailey and Love’s short practice of surgery 28 th edition pg 672</li><li>• Ref :</li><li>• Bailey and Love’s short practice of surgery 28 th edition pg 672</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In the stage of remodelling of wound healing, the ratio of Type III: Type I collagen is:", "options": [{"label": "A", "text": "1:4", "correct": true}, {"label": "B", "text": "4:1", "correct": false}, {"label": "C", "text": "1:3", "correct": false}, {"label": "D", "text": "3:1", "correct": false}], "correct_answer": "A. 1:4", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) 1:4</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All are advantages of split thickness skin grafting except?", "options": [{"label": "A", "text": "Good uptake", "correct": false}, {"label": "B", "text": "Reusable donor site", "correct": false}, {"label": "C", "text": "Less contraction", "correct": true}, {"label": "D", "text": "Large grafts can be harvested", "correct": false}], "correct_answer": "C. Less contraction", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Less contraction</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Good uptake : This is an advantage of split thickness skin grafts because they consist of the epidermis and a variable portion of the dermis , allowing for better integration with the recipient site if it's well-vascularized.</li><li>• Option A. Good uptake</li><li>• advantage of split thickness skin grafts</li><li>• consist of the epidermis and a variable portion of the dermis</li><li>• Option B. Reusable donor site : The donor site from where the split thickness skin graft is taken can heal without scarring and be reused for future grafts because it only involves a portion of the dermis.</li><li>• Option B. Reusable donor site</li><li>• donor site from where the split thickness skin graft</li><li>• taken can heal without scarring</li><li>• reused for future grafts</li><li>• Option D. Large grafts can be harvested : Because split thickness skin grafts involve less of the dermis , larger areas of skin can be harvested as grafts compared to full-thickness grafts.</li><li>• Option D. Large grafts can be harvested</li><li>• split thickness skin grafts</li><li>• less of the dermis</li><li>• larger areas of skin can be harvested</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Split thickness skin grafts offer several benefits, such as good uptake , the potential to reuse the donor site , and the ability to harvest large grafts . However, they are more susceptible to contraction , which is not an advantage of this grafting method.</li><li>➤ Split thickness skin grafts</li><li>➤ several benefits, such as good uptake</li><li>➤ potential to reuse the donor site</li><li>➤ ability to harvest large grafts</li><li>➤ they are more susceptible to contraction</li><li>➤ Partial Thickness (Thiersch) or Split Skin Graft</li><li>➤ Partial Thickness (Thiersch) or Split Skin Graft</li><li>➤ Consist of epidermis and variable portion of dermis Large size graft can be taken Site : Thigh (MC) upper arm, flexor aspect of forearm and abdominal wall Grafts are hairless and do not sweat (these structures are not transferred) Skin graft must be applied to a well-vascularized recipient wound bed. It will not adhere to exposed bone, cartilage, or tendon devoid of periosteum, perichondrium, respectively, or devoid of its vascularized perimembranous envelope.</li><li>➤ Consist of epidermis and variable portion of dermis</li><li>➤ epidermis and variable portion of dermis</li><li>➤ Large size graft can be taken</li><li>➤ Site : Thigh (MC) upper arm, flexor aspect of forearm and abdominal wall</li><li>➤ Site</li><li>➤ Thigh</li><li>➤ upper arm, flexor aspect of forearm and abdominal wall</li><li>➤ Grafts are hairless and do not sweat (these structures are not transferred)</li><li>➤ Skin graft must be applied to a well-vascularized recipient wound bed. It will not adhere to exposed bone, cartilage, or tendon devoid of periosteum, perichondrium, respectively, or devoid of its vascularized perimembranous envelope.</li><li>➤ Causes of skin graft failure: Hematoma (or seroma), infection, and movement (shear). Pie crusting/meshing: Stab incisions in the graft pre-emptively to create small outlets for fluid to drain from beneath the graft</li><li>➤ Causes of skin graft failure: Hematoma (or seroma), infection, and movement (shear).</li><li>➤ Pie crusting/meshing: Stab incisions in the graft pre-emptively to create small outlets for fluid to drain from beneath the graft</li><li>➤ Skin grafts inevitably contract, with the extent of contracture determined by the amount of dermis taken with the graft and the level of postoperative splintage and physiotherapy applied to the grafted site. They are not very cosmetic, and hence avoided on facial wounds.</li><li>➤ Skin grafts inevitably contract, with the extent of contracture determined by the amount of dermis taken with the graft and the level of postoperative splintage and physiotherapy applied to the grafted site. They are not very cosmetic, and hence avoided on facial wounds.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 686 Bailey 27 th Ed. Pg 635</li><li>➤ Ref :</li><li>➤ Bailey and Love’s short practice of surgery 28 th edition pg 686 Bailey 27 th Ed. Pg 635</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of these are features of the wound therapy given below except:", "options": [{"label": "A", "text": "Reduce oedema", "correct": false}, {"label": "B", "text": "Reduce wound exudate", "correct": false}, {"label": "C", "text": "Delay granulation tissue formation", "correct": true}, {"label": "D", "text": "Draw the wound edges together", "correct": false}], "correct_answer": "C. Delay granulation tissue formation", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/11/picture12.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Delay granulation tissue formation.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Reduce oedema : NPWT helps in reducing oedema by applying a negative pressure to the wound , which helps remove excess fluid.</li><li>• Option A. Reduce oedema</li><li>• reducing oedema by applying a negative pressure to the wound</li><li>• Option B. Reduce wound exudate : The system decreases the amount of exudate by suctioning it away , which helps to keep the wound environment optimal for healing.</li><li>• Option B. Reduce wound exudate</li><li>• system decreases the amount of exudate</li><li>• suctioning it away</li><li>• Option D. Draw the wound edges together : NPWT assists in mechanically drawing the edges of the wound together , which can help reduce the size of the wound and promote faster healing.</li><li>• Option D. Draw the wound edges together</li><li>• assists in mechanically drawing the edges of the wound together</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Negative pressure helps draw the wound edges together , remove exudate , reduce oedema and promote granulation tissue formation . NPWT is not recommended in the setting of exposed vessels , malignancy, untreated osteomyelitis, necrotic tissue or non-enteric and unexplored fistulae. A negative pressure of -125 mm of Hg is usually generated by the suction machine</li><li>➤ Negative pressure helps draw the wound edges together , remove exudate , reduce oedema and promote granulation tissue formation .</li><li>➤ Negative pressure helps draw the wound edges together</li><li>➤ remove exudate</li><li>➤ reduce oedema</li><li>➤ promote granulation tissue formation</li><li>➤ NPWT is not recommended in the setting of exposed vessels , malignancy, untreated osteomyelitis, necrotic tissue or non-enteric and unexplored fistulae.</li><li>➤ NPWT is not recommended in the setting of exposed vessels</li><li>➤ A negative pressure of -125 mm of Hg is usually generated by the suction machine</li><li>➤ negative pressure of -125 mm of Hg</li><li>➤ suction machine</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 32</li><li>➤ Ref :</li><li>➤ Bailey and Love’s short practice of surgery 28 th edition pg 32</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "An 18-year-old boy came to the casualty 10 hours after sustaining a laceration on his leg from a motorbike accident. The wound has dirt around it but no signs of infection. How will you manage the wound?", "options": [{"label": "A", "text": "Primary closure", "correct": false}, {"label": "B", "text": "Wound debridement and dressing", "correct": false}, {"label": "C", "text": "Delayed closure", "correct": true}, {"label": "D", "text": "Need more information", "correct": false}], "correct_answer": "C. Delayed closure", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/11/picture14.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/21/screenshot-2024-03-21-175722.png"], "explanation": "<p><strong>Ans. C) Delayed closure</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Primary closure : This refers to the immediate closure of the wound , typically within a few hours of the injury . It is usually not recommended for contaminated wounds or those older than 6 hours due to the risk of trapping bacteria inside, which can lead to infection.</li><li>• Option A. Primary closure</li><li>• immediate closure of the wound</li><li>• few hours of the injury</li><li>• Option B. Wound debridement and dressing : This involves cleaning the wound, removing any nonviable tissue, contaminants, or foreign material , and then applying a dressing without closing the wound . This would be part of the initial management but is not the final step.</li><li>• Option B. Wound debridement and dressing</li><li>• cleaning the wound, removing any nonviable tissue, contaminants, or foreign material</li><li>• dressing without closing the wound</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Ref : Bailey and Love’s short practice of surgery 28 th edition pg 28</li><li>• Ref :</li><li>• Bailey and Love’s short practice of surgery 28 th edition pg 28</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A skin graft will not have good uptake on which of these following recipient beds: Bone Cartilage Muscle Tendon", "options": [{"label": "A", "text": "1 and 2", "correct": false}, {"label": "B", "text": "2 and 4", "correct": false}, {"label": "C", "text": "1,2 and 4", "correct": true}, {"label": "D", "text": "All of these", "correct": false}], "correct_answer": "C. 1,2 and 4", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) 1,2 and 4</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Skin grafts survive initially by imbibition of plasma (day 1-2) from the wound bed; After 48 hours, fine anastomotic connections are made, which lead to inosculation of blood . Capillary ingrowth then completes the healing process with fibroblast maturation. Because only tissues that produce granulation will support a graft, it is usually contraindicated to use grafts to cover exposed tendons, cartilage or cortical bone.</li><li>➤ Skin grafts survive initially by imbibition of plasma (day 1-2) from the wound bed;</li><li>➤ imbibition of plasma</li><li>➤ After 48 hours, fine anastomotic connections are made, which lead to inosculation of blood .</li><li>➤ inosculation of blood</li><li>➤ Capillary ingrowth then completes the healing process with fibroblast maturation.</li><li>➤ Because only tissues that produce granulation will support a graft, it is usually contraindicated to use grafts to cover exposed tendons, cartilage or cortical bone.</li><li>➤ Because only tissues that produce granulation will support a graft, it is usually contraindicated to use grafts to cover exposed tendons, cartilage or cortical bone.</li><li>➤ Ref : Bailey 27 th Ed. Pg 635</li><li>➤ Ref</li><li>➤ : Bailey 27 th Ed. Pg 635</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A man undergoes emergency laparotomy for hemoperitoneum. Due to massive bowel edema, the abdominal wall is left open, and viscera are protected with the device shown. What is the pressure generated by the device (in mm Hg)?", "options": [{"label": "A", "text": "30 mm of Hg", "correct": false}, {"label": "B", "text": "125 mm of Hg", "correct": false}, {"label": "C", "text": "-30 mm of Hg", "correct": false}, {"label": "D", "text": "-125 mm of Hg", "correct": true}], "correct_answer": "D. -125 mm of Hg", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/11/picture15.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. D) -125 mm Hg</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient is managed for fracture tibia by application of above knee cast. He is complaining of excruciating pain in the limb. Toe movements are painful. If a catheter is inserted in the muscle compartment, what should be the pressure threshold for doing a fasciotomy in this patient?", "options": [{"label": "A", "text": "10 mm Hg", "correct": false}, {"label": "B", "text": "20 mm Hg", "correct": false}, {"label": "C", "text": "30 mm Hg", "correct": true}, {"label": "D", "text": "40 mm Hg", "correct": false}], "correct_answer": "C. 30 mm Hg", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) 30 mm Hg</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is not a free flap for breast reconstruction?", "options": [{"label": "A", "text": "TRAM", "correct": false}, {"label": "B", "text": "DIEP", "correct": false}, {"label": "C", "text": "Anterolateral thigh", "correct": false}, {"label": "D", "text": "Latissimus dorsi flap", "correct": true}], "correct_answer": "D. Latissimus dorsi flap", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/22/whatsapp-image-2024-03-22-at-115355-am.jpeg"], "explanation": "<p><strong>Ans. D) Latissimus dorsi flap</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. TRAM (Transverse Rectus Abdominis Myocutaneous) Flap : This flap involves transferring skin, fat, and part of the underlying rectus abdominis muscle to reconstruct the breast. It can be done as a free flap or pedicled flap , which means it is completely detached from its original blood supply and reattached to blood vessels at the breast site using microvascular surgery.</li><li>• Option A. TRAM (Transverse Rectus Abdominis Myocutaneous) Flap</li><li>• flap involves transferring skin, fat, and part of the underlying rectus abdominis muscle to reconstruct the breast.</li><li>• as a free flap or pedicled flap</li><li>• Option B. DIEP (Deep Inferior Epigastric Perforator) Flap : Similar to the TRAM flap but spares the rectus muscle . It uses the skin and fat from the lower abdomen , along with the accompanying blood vessels (deep inferior epigastric perforator artery), and is reattached to the chest blood vessels to form a new breast mound .</li><li>• Option B. DIEP (Deep Inferior Epigastric Perforator) Flap</li><li>• TRAM flap</li><li>• spares the rectus muscle</li><li>• skin and fat from the lower abdomen</li><li>• blood vessels</li><li>• reattached to the chest blood vessels to form a new breast mound</li><li>• Option C. Anterolateral thigh (ALT) Flap : This flap uses skin and fat from the thigh to reconstruct the breast. It is less commonly used than abdominal tissue but is an option for patients who do not have enough abdominal tissue or prefer not to use it.</li><li>• Option C. Anterolateral thigh (ALT) Flap</li><li>• flap uses skin and fat from the thigh to reconstruct the breast.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ A free flap involves detaching tissue from one area of the body with its blood supply and reattaching it to blood vessels at the reconstruction site using microsurgery . In contrast, a pedicled flap maintains its original blood supply during the transfer.</li><li>➤ free flap</li><li>➤ detaching tissue from one area of the body with its blood supply and reattaching it to blood vessels</li><li>➤ reconstruction site using microsurgery</li><li>➤ Breast reconstruction types:</li><li>➤ Breast reconstruction types:</li><li>➤ The easiest type of reconstruction is using a silicone gel implant under the pectoralis major muscle. The lateral portion of the implant, which was traditionally left in the subcutaneous plane, is now increasingly covered by an acellular dermal matrix (ADM). This gives a superior cosmetic result. If the skin at the mastectomy site is poor (e.g. following radiotherapy) or if a larger volume of tissue is required , a musculocutaneous flap can be constructed either from the pedicled latissimus dorsi muscle (an LD flap) or using the transversus abdominis muscle (a pedicled TRAM flap). The latter gives an excellent cosmetic result in experienced hands but is a lengthy procedure and requires careful patient selection. It is now usually performed as a free transfer using microvascular anastomosis, although the pedicled TRAM from the contralateral side is still used. Variations on the TRAM flap requiring less muscle harvesting, such as the free DIEP flap (based on deep inferior epigastric vessels), are increasingly being used. As muscle is spared, post operative hernias are uncommon in DIEP flap.</li><li>➤ The easiest type of reconstruction is using a silicone gel implant under the pectoralis major muscle. The lateral portion of the implant, which was traditionally left in the subcutaneous plane, is now increasingly covered by an acellular dermal matrix (ADM). This gives a superior cosmetic result.</li><li>➤ easiest type of reconstruction is using a silicone gel implant under the pectoralis major muscle.</li><li>➤ If the skin at the mastectomy site is poor (e.g. following radiotherapy) or if a larger volume of tissue is required , a musculocutaneous flap can be constructed either from the pedicled latissimus dorsi muscle (an LD flap) or using the transversus abdominis muscle (a pedicled TRAM flap).</li><li>➤ skin at the mastectomy site is poor</li><li>➤ if a larger volume of tissue is required</li><li>➤ musculocutaneous flap can be constructed</li><li>➤ The latter gives an excellent cosmetic result in experienced hands but is a lengthy procedure and requires careful patient selection.</li><li>➤ It is now usually performed as a free transfer using microvascular anastomosis, although the pedicled TRAM from the contralateral side is still used.</li><li>➤ Variations on the TRAM flap requiring less muscle harvesting, such as the free DIEP flap (based on deep inferior epigastric vessels), are increasingly being used. As muscle is spared, post operative hernias are uncommon in DIEP flap.</li><li>➤ free DIEP flap (based on deep inferior epigastric vessels), are increasingly being used. As muscle is spared, post operative hernias are uncommon in DIEP flap.</li><li>➤ Pedicled TRAM : based on superior epigastric artery Free TRAM : Based on deep inferior epigastric artery DIEP : Based on deep inferior epigastric artery, but muscle sparing</li><li>➤ Pedicled TRAM : based on superior epigastric artery</li><li>➤ Pedicled TRAM</li><li>➤ Free TRAM : Based on deep inferior epigastric artery</li><li>➤ Free TRAM</li><li>➤ DIEP : Based on deep inferior epigastric artery, but muscle sparing</li><li>➤ DIEP</li><li>➤ Ref : Bailey and Love’s short practice of surgery 27 th edition Pg 879</li><li>➤ Ref :</li><li>➤ Bailey and Love’s short practice of surgery 27 th edition Pg 879</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Free radial artery forearm flap (FRAFF) is a type of:", "options": [{"label": "A", "text": "Myocutaneous flap", "correct": false}, {"label": "B", "text": "Osseomyocutaenous flap", "correct": false}, {"label": "C", "text": "Subcutaneous flap", "correct": false}, {"label": "D", "text": "Fasciocutaenous flap", "correct": true}], "correct_answer": "D. Fasciocutaenous flap", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/11/picture18.jpg"], "explanation": "<p><strong>Ans. D) Fasciocutaenous flap</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A. Myocutaneous flap : This type of flap includes both muscle and skin tissue . e.g. Pectoralis major myocutaneous flap.</li><li>• Option A. Myocutaneous flap</li><li>• type of flap includes both muscle and skin tissue</li><li>• Option B. Osseomyocutaneous flap : This flap contains bone, muscle, and skin tissue. E.g. Free fibular flap.</li><li>• Option B. Osseomyocutaneous flap</li><li>• contains bone, muscle, and skin tissue.</li><li>• Option C. Subcutaneous flap : This flap comprises the subcutaneous layer of fat along with the skin but does not include deeper structures like muscle or fascia. e.g. Deltopectoral flap.</li><li>• Option C. Subcutaneous flap</li><li>• comprises the subcutaneous layer of fat along with the skin</li><li>• does not include deeper structures</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Common tissue transfer donor sites:</li><li>• Common tissue transfer donor sites:</li><li>• Muscle only : Latissimus dorsi, Rectus abdominis, Gracilis Myocutaneous : Latissimus dorsi, Transverse rectus abdominis Fasciocutaneous : Radial forearm flap, Scapular, Lateral arm , Anterolateral thigh, Groin Osseous : Fibula (may be cutaneous as well), Forearm (taking sliver of radius bone), Iliac crest Fascial : Temporoparietal</li><li>• Muscle only : Latissimus dorsi, Rectus abdominis, Gracilis</li><li>• Muscle</li><li>• only</li><li>• Myocutaneous : Latissimus dorsi, Transverse rectus abdominis</li><li>• Myocutaneous</li><li>• Fasciocutaneous : Radial forearm flap, Scapular, Lateral arm , Anterolateral thigh, Groin</li><li>• Fasciocutaneous</li><li>• Osseous : Fibula (may be cutaneous as well), Forearm (taking sliver of radius bone), Iliac crest</li><li>• Osseous</li><li>• Fascial : Temporoparietal</li><li>• Fascial</li><li>• Ref : Bailey and Love’s short practice of surgery 28 th edition pg 823-824 Bailey 27 th Ed. Table 42.2</li><li>• Ref :</li><li>• Bailey and Love’s short practice of surgery 28 th edition pg 823-824 Bailey 27 th Ed. Table 42.2</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is also known as ‘Workshorse flap’ for head and neck reconstruction?", "options": [{"label": "A", "text": "Deltopectoral flap", "correct": false}, {"label": "B", "text": "Pectoralis major myo-cutaneous flap (PMMC)", "correct": true}, {"label": "C", "text": "Anterolateral thigh flap", "correct": false}, {"label": "D", "text": "Free fibula osseo-cutaenous flap", "correct": false}], "correct_answer": "B. Pectoralis major myo-cutaneous flap (PMMC)", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Pectoralis major myo-cutaneous flap (PMMC)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Deltopectoral flap : It's used less commonly than the PMMC flap for head and neck reconstruction due to its limited mobility and reach. It is a cutaneous flap.</li><li>• Option A. Deltopectoral flap</li><li>• less commonly than the PMMC flap for head and neck reconstruction</li><li>• Option C. Anterolateral thigh (ALT) Flap : It is a free flap, gaining popularity due to its minimal donor site morbidity and large vessel calibre , used for breast reconstruction.</li><li>• Option C. Anterolateral thigh (ALT) Flap</li><li>• free flap, gaining popularity due to its minimal donor site morbidity and large vessel calibre</li><li>• Option D. Free fibula osseocutaneous flap : This involves transferring a section of the fibula along with muscle and skin for reconstruction , often used to rebuild the mandible after resection of oral cancers.</li><li>• Option D. Free fibula osseocutaneous flap</li><li>• transferring a section of the fibula along with muscle and skin for reconstruction</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ It is important to know the anatomical basis and clinical indications for each type of flap to select the most appropriate one for a given reconstructive challenge. The PMMC flap is especially valuable in settings with limited resources or where microvascular reconstruction is not feasible.</li><li>➤ PMMC flap is especially valuable in settings with limited resources or where microvascular reconstruction is not feasible.</li><li>➤ Ref : Online resource:</li><li>➤ Ref : Online resource:</li><li>➤ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4668731/#:~:text=PMMC%20flap%20is%20a%20versatile,in%20head%20and%20neck%20reconstruction .</li><li>➤ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4668731/#:~:text=PMMC%20flap%20is%20a%20versatile,in%20head%20and%20neck%20reconstruction</li><li>➤ .</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is not a phase of graft uptake?", "options": [{"label": "A", "text": "Plasmatic imbibition", "correct": false}, {"label": "B", "text": "Inflammation", "correct": true}, {"label": "C", "text": "Inosculation", "correct": false}, {"label": "D", "text": "Neovascularization", "correct": false}], "correct_answer": "B. Inflammation", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/21/screenshot-2024-03-21-184050.png"], "explanation": "<p><strong>Ans. B) Inflammation</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Skin graft occurs in three phases . The first phase consists of plasmatic imbibition and lasts 24– 48 hours . This is followed by an inosculatory phase and a process of capillary ingrowth that occur essentially simultaneously until generalized blood flow has been established by the fifth or sixth post-graft day . The third phase is neovascularization.</li><li>➤ Skin graft occurs in three phases</li><li>➤ first phase</li><li>➤ plasmatic imbibition</li><li>➤ lasts 24– 48 hours</li><li>➤ inosculatory phase</li><li>➤ process of capillary ingrowth that occur essentially simultaneously until generalized blood flow</li><li>➤ fifth or sixth post-graft day</li><li>➤ Ref : Online resource chromeextension://efaidnbmnnnibpcajpcglclefindmkaj/https://plasticsurgery.stanford.edu/content/dam/sm/plasticsurgery/documents/education/microsurgery/FlapsSelectedReadings.pdf Bailey 27 th Ed. Pg 635</li><li>➤ Ref :</li><li>➤ Online resource chromeextension://efaidnbmnnnibpcajpcglclefindmkaj/https://plasticsurgery.stanford.edu/content/dam/sm/plasticsurgery/documents/education/microsurgery/FlapsSelectedReadings.pdf Bailey 27 th Ed. Pg 635</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the correct statement about skin graft:", "options": [{"label": "A", "text": "Primary contracture is seen in STSG", "correct": false}, {"label": "B", "text": "Secondary contracture is seen in Full thickness skin graft", "correct": false}, {"label": "C", "text": "Both A and B", "correct": false}, {"label": "D", "text": "Neither A nor B", "correct": true}], "correct_answer": "D. Neither A nor B", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Neither A nor B</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A. Primary contracture is seen in STSG (Split Thickness Skin Graft): This statement is incorrect because primary contracture refers to the immediate shrinkage of a wound or graft , and it is not typically associated with STSG . STSG usually undergoes secondary contracture due to its lack of intact myocytes.</li><li>• Option A.</li><li>• Primary contracture is seen in STSG</li><li>• incorrect</li><li>• primary contracture refers to the immediate shrinkage of a wound or graft</li><li>• not typically associated with STSG</li><li>• Option B . Secondary contracture is seen in Full Thickness Skin Graft (FTSG): This is also incorrect . FTSGs are less prone to secondary contracture because they include the full dermis, which retains more of the skin's natural elasticity . They undergo primary contracture.</li><li>• Option B</li><li>• Secondary contracture is seen in Full Thickness Skin Graft</li><li>• incorrect</li><li>• FTSGs</li><li>• less prone to secondary contracture</li><li>• full dermis, which retains more of the skin's natural elasticity</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Full thickness skin graft contains myocytes and thereby undergoes primary contracture. STSG does not contain intact myocytes and thereby undergoes secondary contracture with an unsightly scar. Skin grafts inevitably contract, with the extent of contracture determined by the amount of dermis taken with the graft and the level of postoperative splintage and physiotherapy applied to the grafted site. Full-thickness skin grafts consist of epidermis and dermis . As they include the entire thickness of the dermis, they retain their elasticity and are less prone to secondary scar contracture . However, this also means that the area harvested is limited by the ability to primarily close the donor site. The common sites for harvest include the supraclavicular skin, groin crease and posterior auricular region (known as a Wolfe graft), where there is adequate skin laxity. Full-thickness grafts are commonly used for syndactyly release in the hand, reconstruction of facial defects following skin cancer excision or contracture releases following burns. Composite skin grafts are a combination of skin and another tissue type , such as fat or cartilage . A commonly used composite skin graft is to harvest a skin/cartilage graft from the helical root of the ear to reconstruct the alar of the nose following skin cancer excision. A hair-bearing composite scalp graft can be used to reconstruct an eyebrow.</li><li>➤ Full thickness skin graft contains myocytes and thereby undergoes primary contracture.</li><li>➤ Full thickness skin graft</li><li>➤ myocytes</li><li>➤ undergoes primary contracture.</li><li>➤ STSG does not contain intact myocytes and thereby undergoes secondary contracture with an unsightly scar.</li><li>➤ STSG does not contain intact myocytes</li><li>➤ undergoes secondary contracture</li><li>➤ Skin grafts inevitably contract, with the extent of contracture determined by the amount of dermis taken with the graft and the level of postoperative splintage and physiotherapy applied to the grafted site.</li><li>➤ Full-thickness skin grafts consist of epidermis and dermis . As they include the entire thickness of the dermis, they retain their elasticity and are less prone to secondary scar contracture . However, this also means that the area harvested is limited by the ability to primarily close the donor site. The common sites for harvest include the supraclavicular skin, groin crease and posterior auricular region (known as a Wolfe graft), where there is adequate skin laxity. Full-thickness grafts are commonly used for syndactyly release in the hand, reconstruction of facial defects following skin cancer excision or contracture releases following burns.</li><li>➤ Full-thickness skin grafts</li><li>➤ epidermis and dermis</li><li>➤ thickness of the dermis, they retain their elasticity and are less prone to secondary scar contracture</li><li>➤ Composite skin grafts are a combination of skin and another tissue type , such as fat or cartilage . A commonly used composite skin graft is to harvest a skin/cartilage graft from the helical root of the ear to reconstruct the alar of the nose following skin cancer excision. A hair-bearing composite scalp graft can be used to reconstruct an eyebrow.</li><li>➤ Composite skin grafts</li><li>➤ combination of skin and another tissue type</li><li>➤ fat or cartilage</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 687</li><li>➤ Ref :</li><li>➤ Bailey and Love’s short practice of surgery 28 th edition pg 687</li><li>➤ Bailey 27 th Ed. Pg635</li><li>➤ Bailey 27 th Ed. Pg635</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the type of flap shown in the image:", "options": [{"label": "A", "text": "Z plasty", "correct": false}, {"label": "B", "text": "VY plasty", "correct": true}, {"label": "C", "text": "YV plasty", "correct": false}, {"label": "D", "text": "Fan flap", "correct": false}], "correct_answer": "B. VY plasty", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/11/picture20.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/11/picture21.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/11/picture22.jpg"], "explanation": "<p><strong>Ans. B) VY Plasty</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "According to reconstructive ladder principle, best cosmetic outcome is seen in:", "options": [{"label": "A", "text": "Full thickness skin graft", "correct": false}, {"label": "B", "text": "Local flap", "correct": false}, {"label": "C", "text": "Pedicle flap", "correct": false}, {"label": "D", "text": "Free flap", "correct": true}], "correct_answer": "D. Free flap", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Free flap.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Full thickness skin graft : This involves the transfer of the epidermis and the entire dermis from the donor site to the recipient site . While it can provide a good cosmetic result, it may not match the texture and contours of the surrounding tissue as well as a flap can.</li><li>• Option A. Full thickness skin graft</li><li>• transfer of the epidermis and the entire dermis from the donor site to the recipient site</li><li>• Option B. Local flap : This uses tissue from an area immediately adjacent to the defect. It has the advantage of using tissue similar to the defect area in color and texture, but the cosmetic outcome can be limited by the size and flexibility of the adjacent tissue.</li><li>• Option B. Local flap</li><li>• uses tissue from an area immediately adjacent to the defect.</li><li>• Option C. Pedicle flap : This maintains its original blood supply during the transfer . While it can provide a reliable reconstruction, the cosmetic outcome may be compromised due to the bulk and rigidity of the pedicle.</li><li>• Option C. Pedicle flap</li><li>• maintains its original blood supply during the transfer</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The reconstructive ladder concept highlights the progression from simple to complex techniques. A free flap , while technically more demanding, generally offers the best cosmetic and functional outcomes in reconstructive surgery because of the precise matching of tissue characteristics and the restoration of blood supply.</li><li>➤ reconstructive ladder concept highlights the progression from simple to complex techniques.</li><li>➤ free flap</li><li>➤ demanding, generally offers the best cosmetic and functional outcomes in reconstructive surgery</li><li>➤ Plastic surgery offers a variety of techniques to address clinical problems . Sometimes, a problem is managed using a ‘ladder’ approach, with the simplest methods being used first and only moving to more complex methods when absolutely necessary. However, this is frequently not the ideal approach for best outcomes. If resources permit, it is often more cost-effective and better functionally for the patient to begin with a more complex treatment, with other easier management options held in reserve as ‘lifeboats’. Plastic surgeons now prefer to think of the range of options available as a toolbox from which they can take the most appropriate method to solve a problem Microsurgery and perforator flaps : With fine instruments and materials , it has become commonplace to be able to disconnect the blood supply of the flap from its donor site and reconnect it in a distant place using the operating microscope. Free tissue transfer is now the best means of reconstructing major composite loss of tissue in the face, jaws, lower limb and many other body sites, as long as resources allow.</li><li>➤ Plastic surgery offers a variety of techniques to address clinical problems . Sometimes, a problem is managed using a ‘ladder’ approach, with the simplest methods being used first and only moving to more complex methods when absolutely necessary. However, this is frequently not the ideal approach for best outcomes.</li><li>➤ Plastic surgery</li><li>➤ variety of techniques to address clinical problems</li><li>➤ If resources permit, it is often more cost-effective and better functionally for the patient to begin with a more complex treatment, with other easier management options held in reserve as ‘lifeboats’.</li><li>➤ resources permit,</li><li>➤ cost-effective</li><li>➤ Plastic surgeons now prefer to think of the range of options available as a toolbox from which they can take the most appropriate method to solve a problem</li><li>➤ Microsurgery and perforator flaps : With fine instruments and materials , it has become commonplace to be able to disconnect the blood supply of the flap from its donor site and reconnect it in a distant place using the operating microscope.</li><li>➤ Microsurgery and perforator flaps</li><li>➤ fine instruments and materials</li><li>➤ become commonplace to be able to disconnect the blood supply of the flap</li><li>➤ Free tissue transfer is now the best means of reconstructing major composite loss of tissue in the face, jaws, lower limb and many other body sites, as long as resources allow.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 823-824</li><li>➤ Ref :</li><li>➤ Bailey and Love’s short practice of surgery 28 th edition pg 823-824</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "This dermatological disease is slow growing, affects white skinned people exclusively and biopsy shows palisading arrangement of cells. What is the disease?", "options": [{"label": "A", "text": "Squamous Cell Ca", "correct": false}, {"label": "B", "text": "Basal Cell Ca", "correct": true}, {"label": "C", "text": "Malignant melanoma", "correct": false}, {"label": "D", "text": "Dermatofibroma protuberans", "correct": false}], "correct_answer": "B. Basal Cell Ca", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Basal Cell Ca</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A. Squamous Cell Carcinoma (SCC): This type of skin cancer arises from the squamous cells in the epidermis . It can be aggressive and may spread to other parts of the body. It is not characterized by a palisading arrangement of cells but shows keratin pearls.</li><li>• Option A. Squamous Cell Carcinoma (SCC):</li><li>• skin cancer arises from the squamous cells in the epidermis</li><li>• Option C. Malignant Melanoma : This is a serious form of skin cancer that arises from melanocytes. It is known for its rapid spread and aggressive nature and does not feature a palisading arrangement of cells.</li><li>• Option C. Malignant Melanoma</li><li>• serious form of skin cancer that arises from melanocytes.</li><li>• Option D. Dermatofibroma Protuberans : This is likely a misnomer or incorrect term for Dermatofibrosarcoma Protuberans , which is a rare type of skin cancer that arises from the dermal layer of the skin and is characterized by spindle-shaped cells in a storiform pattern, not palisading cells.</li><li>• Option D. Dermatofibroma Protuberans</li><li>• misnomer or incorrect term for Dermatofibrosarcoma Protuberans</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Basal Cell Carcinoma is the most common skin cancer associated with ultraviolet radiation exposure , affecting predominantly white-skinned individuals , and is characterized histologically by a palisading arrangement of cells . This is usually a slow growing, locally invasive, malignant tumour of pluripotential epithelial cells arising from basal epidermis and hair follicles; hence, it affects the pilosebaceous skin The strongest predisposing factor to BCC is UVR . It occurs in the elderly or the middle-aged after excessive sun exposure , with 95% occurring between the ages of 40 and 80 years. Other predisposing factors include exposure to arsenical compounds, coal tar, aromatic hydrocarbons and IR and genetic skin cancer syndromes. White-skinned people are almost exclusively affected BCCs can be divided into localised (nodular, nodulocystic, cystic, pigmented and naevoid) and generalised (superficial: multifocal and superficial spreading; or infiltrative: morphoeic, ice pick and cicatrising). Nodular and nodulocystic variants account for 90% of BCCs . The characteristic finding is of ovoid cells in nests with a single palisading layer. Morphoeic BCCs synthesise type 4 collagenase and so spread rapidly. Tumour and surrounding surgical margins should always be assessed and marked under loupe magnification, the latter varying between 2 and 15 mm depending on the macroscopic variant. Where margins are ill-defined or tissue is at a premium (nose, eyes), either a two-stage surgical approach with subsequent reconstruction after confirmation of clear margins or Mohs’ micro-graphic surgery is advisable. The histological sample must be orientated and marked for pathological examination.</li><li>➤ Basal Cell Carcinoma is the most common skin cancer associated with ultraviolet radiation exposure , affecting predominantly white-skinned individuals , and is characterized histologically by a palisading arrangement of cells . This is usually a slow growing, locally invasive, malignant tumour of pluripotential epithelial cells arising from basal epidermis and hair follicles; hence, it affects the pilosebaceous skin</li><li>➤ Basal Cell Carcinoma</li><li>➤ common skin cancer</li><li>➤ ultraviolet radiation exposure</li><li>➤ white-skinned individuals</li><li>➤ palisading arrangement of cells</li><li>➤ The strongest predisposing factor to BCC is UVR . It occurs in the elderly or the middle-aged after excessive sun exposure , with 95% occurring between the ages of 40 and 80 years.</li><li>➤ strongest predisposing factor to BCC is UVR</li><li>➤ elderly or the middle-aged after excessive sun exposure</li><li>➤ Other predisposing factors include exposure to arsenical compounds, coal tar, aromatic hydrocarbons and IR and genetic skin cancer syndromes. White-skinned people are almost exclusively affected</li><li>➤ BCCs can be divided into localised (nodular, nodulocystic, cystic, pigmented and naevoid) and generalised (superficial: multifocal and superficial spreading; or infiltrative: morphoeic, ice pick and cicatrising).</li><li>➤ Nodular and nodulocystic variants account for 90% of BCCs .</li><li>➤ Nodular and nodulocystic variants account for 90% of BCCs</li><li>➤ The characteristic finding is of ovoid cells in nests with a single palisading layer.</li><li>➤ Morphoeic BCCs synthesise type 4 collagenase and so spread rapidly.</li><li>➤ Morphoeic BCCs synthesise type 4 collagenase and so spread rapidly.</li><li>➤ Tumour and surrounding surgical margins should always be assessed and marked under loupe magnification, the latter varying between 2 and 15 mm depending on the macroscopic variant.</li><li>➤ Where margins are ill-defined or tissue is at a premium (nose, eyes), either a two-stage surgical approach with subsequent reconstruction after confirmation of clear margins or Mohs’ micro-graphic surgery is advisable. The histological sample must be orientated and marked for pathological examination.</li><li>➤ Ref : Bailey 28 th Ed. Pg 651-52</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 651-52</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "The pathology shown in the image is a variant of:", "options": [{"label": "A", "text": "Squamous cell Ca", "correct": true}, {"label": "B", "text": "Basal Cell Ca", "correct": false}, {"label": "C", "text": "Malignant melanoma", "correct": false}, {"label": "D", "text": "Sebaceous cyst", "correct": false}], "correct_answer": "A. Squamous cell Ca", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/11/picture23.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. A) Squamous cell Ca</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Four BCCs occur for every SCC, which is the second most common form of skin cancer. It is strongly related to cumulative sun exposure and damage, especially in white-skinned individuals living nearer the equator. SCC is also associated with chronic inflammation (chronic sinus tracts, pre-existing scars, osteomyelitis, burns, vaccination points) and immunosuppression. When a SCC appears in a scar it is known as a Marjolin’s ulcer. The ulcers have a characteristic everted edge and are surrounded by inflamed, indurated skin . Site : SCCs on the lips and ears have higher local recurrence rates than lesions elsewhere, and tumours at the extremities fare worse than those on the trunk. Aetiology : SCCs that arise in burn scars, osteomyelitis skin sinuses, chronic ulcers and areas of skin that have been irradiated have a higher metastatic potential. Immunosuppression: SCCs will invade further in those with impaired immune response. Surgical excision is the only means of providing accurate information on histology and clearance. The margins for primary excision should be tailored to surface size in the first instance. This should ideally be assessed using surgical loupe magnification. A 4-mm clearance margin should be achieved if the SCC measures 2 cm and a 1-cm clearance margin if the SCC measures &gt;2 cm;</li><li>➤ Four BCCs occur for every SCC, which is the second most common form of skin cancer. It is strongly related to cumulative sun exposure and damage, especially in white-skinned individuals living nearer the equator.</li><li>➤ SCC, which is the second most common form of skin cancer.</li><li>➤ SCC is also associated with chronic inflammation (chronic sinus tracts, pre-existing scars, osteomyelitis, burns, vaccination points) and immunosuppression. When a SCC appears in a scar it is known as a Marjolin’s ulcer.</li><li>➤ SCC</li><li>➤ associated with chronic inflammation</li><li>➤ When a SCC appears in a scar it is known as a Marjolin’s ulcer.</li><li>➤ The ulcers have a characteristic everted edge and are surrounded by inflamed, indurated skin .</li><li>➤ ulcers have a characteristic everted edge</li><li>➤ surrounded by inflamed, indurated skin</li><li>➤ Site : SCCs on the lips and ears have higher local recurrence rates than lesions elsewhere, and tumours at the extremities fare worse than those on the trunk.</li><li>➤ Site</li><li>➤ Aetiology : SCCs that arise in burn scars, osteomyelitis skin sinuses, chronic ulcers and areas of skin that have been irradiated have a higher metastatic potential.</li><li>➤ Aetiology</li><li>➤ Immunosuppression: SCCs will invade further in those with impaired immune response.</li><li>➤ Immunosuppression:</li><li>➤ Surgical excision is the only means of providing accurate information on histology and clearance.</li><li>➤ The margins for primary excision should be tailored to surface size in the first instance. This should ideally be assessed using surgical loupe magnification.</li><li>➤ The margins for primary excision should be tailored to surface size in the first instance. This should ideally be assessed using surgical loupe magnification.</li><li>➤ A 4-mm clearance margin should be achieved if the SCC measures 2 cm and a 1-cm clearance margin if the SCC measures &gt;2 cm;</li><li>➤ A 4-mm clearance margin should be achieved if the SCC measures 2 cm and a 1-cm clearance margin if the SCC measures &gt;2 cm;</li><li>➤ Ref : Bailey 28 th Ed. Pg 653-655</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 653-655</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is the most important prognostic indicator of malignant melanoma?", "options": [{"label": "A", "text": "Tumor diameter", "correct": false}, {"label": "B", "text": "Tumor depth", "correct": true}, {"label": "C", "text": "Location", "correct": false}, {"label": "D", "text": "Histological type", "correct": false}], "correct_answer": "B. Tumor depth", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Tumor depth</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Tumor diameter : While larger tumors can indicate a worse prognosis , the diameter is not the most important factor.</li><li>• Option A. Tumor diameter</li><li>• larger tumors can indicate a worse prognosis</li><li>• Option C. Location : The location of the melanoma can influence the prognosis , with certain areas like the soles of the feet, palms, and subungual regions being associated with a poorer prognosis. However, it is not the most important factor.</li><li>• Option C. Location</li><li>• location of the melanoma can influence the prognosis</li><li>• areas like the soles of the feet, palms, and subungual regions</li><li>• Option D. Histological type : There are different histological types of melanoma, some of which may have a worse prognosis than others , but the histological type is not as significant a prognostic indicator as the depth of the tumor.</li><li>• Option D. Histological type</li><li>• different histological types of melanoma,</li><li>• worse prognosis than others</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Breslow thickness , which measures the depth of invasion of a melanoma , is the single most important prognostic indicator for patients without lymph node metastases . This measurement is essential in staging the disease, guiding treatment decisions, and estimating the patient's prognosis.</li><li>➤ Breslow thickness</li><li>➤ depth of invasion of a melanoma</li><li>➤ single most important prognostic indicator for patients without lymph node metastases</li><li>➤ Melanoma is a cancer of melanocytes and can, therefore, arise in skin, mucosa, retina and the leptomeninges. It is the commonest cancer in young adults (20–39 years) and the most likely cause of cancer-related death.</li><li>➤ Melanoma is a cancer of melanocytes and can, therefore, arise in skin, mucosa, retina and the leptomeninges.</li><li>➤ Melanoma</li><li>➤ cancer of melanocytes</li><li>➤ arise in skin, mucosa, retina and the leptomeninges.</li><li>➤ It is the commonest cancer in young adults (20–39 years) and the most likely cause of cancer-related death.</li><li>➤ Macroscopic features in naevi suggestive of malignant melanoma</li><li>➤ Macroscopic features in naevi suggestive of malignant melanoma</li><li>➤ Change in size or shape or Colour or Thickness (elevation/nodularity or ulceration) Satellite lesions (pigment spreading into surrounding area) Tingling/itching/serosanguineous discharge (usually late signs)</li><li>➤ Change in size or shape or Colour or Thickness (elevation/nodularity or ulceration)</li><li>➤ Satellite lesions (pigment spreading into surrounding area)</li><li>➤ Tingling/itching/serosanguineous discharge (usually late signs)</li><li>➤ Biopsy and pathological examination provide the first step towards staging melanoma. The Breslow thickness of a melanoma (measured to the nearest 0.1 mm from the granular layer to the base of the tumour) is the most important prognostic indicator in the absence of lymph node metastases.</li><li>➤ Biopsy and pathological examination provide the first step towards staging melanoma. The Breslow thickness of a melanoma (measured to the nearest 0.1 mm from the granular layer to the base of the tumour) is the most important prognostic indicator in the absence of lymph node metastases.</li><li>➤ For melanoma in situ a wide excision of 5 mm is sufficient. For melanoma &lt; 1mm deep, a 1-cm margin is sufficient. For deeper lesions, a 2-cm margin is recommended.</li><li>➤ For melanoma in situ a wide excision of 5 mm is sufficient.</li><li>➤ For melanoma &lt; 1mm deep, a 1-cm margin is sufficient.</li><li>➤ For deeper lesions, a 2-cm margin is recommended.</li><li>➤ Completion lymphadenectomy after positive SLNB remains, on current evidence, the optimum method for regional control.</li><li>➤ Ref : Bailey 28 th Ed. Pg 655-658</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 655-658</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A woman was brought to the casualty 2 hours after sustaining burns on the abdomen, both the limbs and back. What will be the formula to calculate amount of fluid to be replenished as per Parkland’s?", "options": [{"label": "A", "text": "4 mL/kg × % TBSA of colloids + crystalloids", "correct": false}, {"label": "B", "text": "4 mL/kg × %TBSA of crystalloids alone", "correct": true}, {"label": "C", "text": "2 mL/kg × %TBSA of colloids alone", "correct": false}, {"label": "D", "text": "2mL/kg × %TBSA of crystalloids and colloids", "correct": false}], "correct_answer": "B. 4 mL/kg × %TBSA of crystalloids alone", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/11/picture24.jpg"], "explanation": "<p><strong>Ans. B) 4 mL/kg × %TBSA of crystalloids alone</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these burns mechanisms is unlikely to cause a deep or full thickness burn?", "options": [{"label": "A", "text": "Scald", "correct": true}, {"label": "B", "text": "Fat burns", "correct": false}, {"label": "C", "text": "Electrical burn", "correct": false}, {"label": "D", "text": "Strong concentration acid burns", "correct": false}], "correct_answer": "A. Scald", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/21/screenshot-2024-03-21-190301.png"], "explanation": "<p><strong>Ans. A) Scald</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Ref : Bailey and Love’s short practice of surgery 28 th edition pg 669, table 46.2</li><li>• Ref :</li><li>• Bailey and Love’s short practice of surgery 28 th edition pg 669, table 46.2</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A child has scald burns on both of his hands due to hot water treatment. The lesion is pink, oozing and painful to air and touch. What is the depth?", "options": [{"label": "A", "text": "First degree burn", "correct": false}, {"label": "B", "text": "Second degree superficial burn", "correct": true}, {"label": "C", "text": "Second degree deep burn", "correct": false}, {"label": "D", "text": "Third degree burn", "correct": false}], "correct_answer": "B. Second degree superficial burn", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/21/screenshot-2024-03-21-190816.png"], "explanation": "<p><strong>Ans. B) Second degree superficial</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. First Degree : Also known as epidermal burns , these affect only the outer layer of skin, the epidermis . The skin is typically red and painful, but there is no blistering, and it does not ooze.</li><li>• Option A. First Degree</li><li>• epidermal burns</li><li>• affect only the outer layer of skin, the epidermis</li><li>• Option C. Second Degree Deep : A deeper second-degree burn affects deeper layers of the dermis and may present without pain if nerve endings are damaged. The skin may appear white or mottled and will not be as pliable.</li><li>• Option C. Second Degree Deep</li><li>• deeper second-degree burn</li><li>• deeper layers of the dermis and may present without pain if nerve endings are damaged.</li><li>• Option D. Third Degree : This burn affects the full thickness of the skin, destroying both the epidermis and dermis . It can extend into the subcutaneous tissue. The area may be white, brown, or black, and it is often painless initially due to nerve destruction.</li><li>• Option D. Third Degree</li><li>• full thickness of the skin, destroying both the epidermis and dermis</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Ref : Bailey and Love’s short practice of surgery 28 th edition 669-671</li><li>• Ref :</li><li>• Bailey and Love’s short practice of surgery 28 th edition 669-671</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these statements is not true regarding third degree burns?", "options": [{"label": "A", "text": "All skin appendages are destroyed", "correct": false}, {"label": "B", "text": "Lesions are very painful and require application of anesthetic agents", "correct": true}, {"label": "C", "text": "Skin is white, charred, leathery and does not blanch", "correct": false}, {"label": "D", "text": "Contractures and scarring is seen", "correct": false}], "correct_answer": "B. Lesions are very painful and require application of anesthetic agents", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/21/screenshot-2024-03-21-190816_D3YaxDv.png"], "explanation": "<p><strong>Ans. B) Lesions are very painful and require application of anesthetic agents.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A. All skin appendages are destroyed : Third-degree burns extend through the full thickness of the skin , involving the epidermis, dermis, and often the underlying structures, leading to the destruction of all skin appendages such as hair follicles, sweat glands, and sebaceous glands.</li><li>• Option A. All skin appendages are destroyed</li><li>• full thickness of the skin</li><li>• epidermis, dermis, and often the underlying structures,</li><li>• destruction of all skin appendages</li><li>• Option C. Skin is white, charred, leathery, and does not blanch : Third-degree burns result in a white or charred appearance , and the skin becomes leathery .</li><li>• Option C. Skin is white, charred, leathery, and does not blanch</li><li>• result in a white or charred appearance</li><li>• skin becomes leathery</li><li>• Option D. Contractures and scarring are seen : Third-degree burns can lead to the formation of contractures and extensive scarring (eschar) as the healing process involves the contraction of the surrounding tissue .</li><li>• Option D. Contractures and scarring are seen</li><li>• formation of contractures and extensive scarring</li><li>• healing process</li><li>• contraction of the surrounding tissue</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Third-degree burns are typically painless or have reduced sensation due to nerve destruction , making the application of anesthetic agents unnecessary for pain management .</li><li>• Third-degree burns</li><li>• painless or have reduced sensation due to nerve destruction</li><li>• application of anesthetic agents</li><li>• pain management</li><li>• Third degree burns are not painful and have no sensation as nerves are destroyed .</li><li>• Third degree burns</li><li>• painful and have no sensation as nerves are destroyed</li><li>• BURNS</li><li>• BURNS</li><li>• Ref : Bailey and Love’s short practice of surgery 28 th edition 669-671</li><li>• Ref : Bailey and Love’s short practice of surgery 28 th edition 669-671</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 5-year-old child spills boiling water accidentally over her face and trunk. Which of the following methods is most correct to estimate the body surface area involved in burns?", "options": [{"label": "A", "text": "Palm method", "correct": false}, {"label": "B", "text": "Rule of 9", "correct": false}, {"label": "C", "text": "Lund and Browder chart", "correct": true}, {"label": "D", "text": "Berkow tables", "correct": false}], "correct_answer": "C. Lund and Browder chart", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Lund and Browder chart</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A. Palm method : The patient's hand is approximately 1% of the total body surface area (TBSA) and can be used as a quick guide for small or patchy burns.</li><li>• Option A.</li><li>• Palm method</li><li>• patient's hand is approximately 1% of the total body surface area</li><li>• Option B . Rule of 9 : The Wallace Rule of Nines is commonly used in adults . It divides the body into regions , each representing 9% or a multiple of 9%. This method is less accurate for children due to differences in body proportions.</li><li>• Option B</li><li>• Rule of 9</li><li>• Wallace Rule of Nines is commonly used in adults</li><li>• divides the body into regions</li><li>• representing 9% or a multiple of 9%.</li><li>• Option D . Berkow tables : Berkow formula is used to accurately determine burn size according to age , and it provides a more individualized approach than the Rule of 9.</li><li>• Option D</li><li>• Berkow tables</li><li>• accurately determine burn size according to age</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Lund and Browder chart is the preferred method for estimating burn size in children, considering their changing body proportions . This chart provides a more accurate assessment compared to the Rule of 9, especially in pediatric cases.</li><li>➤ Lund and Browder chart is the preferred method for estimating burn size in children,</li><li>➤ changing body proportions</li><li>➤ Burn Size (% BSA):</li><li>➤ Burn Size (% BSA):</li><li>➤ Burn size is assessed by Wallace rule of nines . An infant’s head is proportionally larger than an adult’s and this adjustment is represented on the modified Lund and Browder chart for children , where at birth the head represents 18% and the lower limbs 13.5% each. For each year 1% is subtracted from the head, with 0.5% being added to each lower limb until the age of 10, when the body proportions are roughly equivalent to those of an adult. For estimating smaller burns: Area of open hand (including palm and extended fingers) of the patient is approximately 1% of TBSA.</li><li>➤ Burn size is assessed by Wallace rule of nines .</li><li>➤ Burn size is assessed by Wallace rule of nines</li><li>➤ An infant’s head is proportionally larger than an adult’s and this adjustment is represented on the modified Lund and Browder chart for children , where at birth the head represents 18% and the lower limbs 13.5% each. For each year 1% is subtracted from the head, with 0.5% being added to each lower limb until the age of 10, when the body proportions are roughly equivalent to those of an adult.</li><li>➤ infant’s head is proportionally larger than an adult’s</li><li>➤ adjustment is represented on the modified Lund and Browder chart for children</li><li>➤ For estimating smaller burns: Area of open hand (including palm and extended fingers) of the patient is approximately 1% of TBSA.</li><li>➤ Wallace Rule of Nine*</li><li>➤ Wallace Rule of Nine*</li><li>➤ In adults : Each upper extremity: 9% Head and neck: 9% Lower extremities: 18% Anterior and posterior aspects of the trunk: 18% Perineum and genitalia: 1%</li><li>➤ In adults : Each upper extremity: 9% Head and neck: 9% Lower extremities: 18% Anterior and posterior aspects of the trunk: 18% Perineum and genitalia: 1%</li><li>➤ In adults</li><li>➤ Each upper extremity: 9% Head and neck: 9% Lower extremities: 18% Anterior and posterior aspects of the trunk: 18% Perineum and genitalia: 1%</li><li>➤ Each upper extremity: 9%</li><li>➤ Head and neck: 9%</li><li>➤ Lower extremities: 18%</li><li>➤ Anterior and posterior aspects of the trunk: 18%</li><li>➤ Perineum and genitalia: 1%</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition Pg 668</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition Pg 668</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient suffers from a third-degree circumferential burn in the arm and forearm region. Which of the following should be monitored in these patients?", "options": [{"label": "A", "text": "Blood glucose levels", "correct": false}, {"label": "B", "text": "Carboxyhemoglobin level", "correct": false}, {"label": "C", "text": "Myoglobinuria", "correct": false}, {"label": "D", "text": "Peripheral pulse and circulation", "correct": true}], "correct_answer": "D. Peripheral pulse and circulation", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/11/picture28_c7m1tIh.jpg"], "explanation": "<p><strong>Ans. D) Peripheral pulse and circulation</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ It is important to monitor peripheral pulse and circulation in cases of circumferential burns to prevent complications associated with compromised blood flow (compartment syndrome) due to tourniquet effect by eschar .</li><li>➤ monitor peripheral pulse</li><li>➤ circulation</li><li>➤ circumferential burns to prevent complications</li><li>➤ compromised blood flow</li><li>➤ eschar</li><li>➤ When deep second and third-degree wounds encompass the circumference of an extremity peripheral circulation to the limb can be compromised. Development of generalized edema beneath a non-yielding eschar impedes venous outflow and affects arterial inflow to the distal beds. This can be recognized by numbness and tingling in the limb and increased pain in digits. Circumferential full-thickness burns to the limbs and torso require emergency surgery in the form of escharotomy. The tourniquet effect of this injury is treated by incising the whole length of full-thickness burns</li><li>➤ When deep second and third-degree wounds encompass the circumference of an extremity peripheral circulation to the limb can be compromised.</li><li>➤ Development of generalized edema beneath a non-yielding eschar impedes venous outflow and affects arterial inflow to the distal beds.</li><li>➤ This can be recognized by numbness and tingling in the limb and increased pain in digits.</li><li>➤ Circumferential full-thickness burns to the limbs and torso require emergency surgery in the form of escharotomy. The tourniquet effect of this injury is treated by incising the whole length of full-thickness burns</li><li>➤ Circumferential full-thickness burns to the limbs and torso require emergency surgery in the form of escharotomy. The tourniquet effect of this injury is treated by incising the whole length of full-thickness burns</li><li>➤ Image shows circumferential full thickness burns on lower limb with longitudinal escharotomy.</li><li>➤ Image shows circumferential full thickness burns on lower limb with longitudinal escharotomy.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition 673</li><li>➤ Ref :</li><li>➤ Bailey and Love’s short practice of surgery 28 th edition 673</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "What would be the safest strategy of treatment for a patient of inhalational burn injury who has presented within 3-4 hours of burns?", "options": [{"label": "A", "text": "Binasal catheter O2 inhalation", "correct": false}, {"label": "B", "text": "O2 therapy with well fitting face mask", "correct": false}, {"label": "C", "text": "Elective cricothyroidotomy", "correct": false}, {"label": "D", "text": "Elective endotracheal intubation", "correct": true}], "correct_answer": "D. Elective endotracheal intubation", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Elective endotracheal intubation</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A . Binasal Catheter O2 Inhalation:</li><li>• Option A</li><li>• Binasal Catheter O2 Inhalation:</li><li>• This method may provide supplemental oxygen but does not address the potential complications of airway swelling associated with inhalational burn injury.</li><li>• This method may provide supplemental oxygen but does not address the potential complications of airway swelling associated with inhalational burn injury.</li><li>• provide supplemental oxygen</li><li>• Option B . O2 Therapy with Well-Fitting Face Mask:</li><li>• Option B</li><li>• O2 Therapy with Well-Fitting Face Mask:</li><li>• While a well-fitting face mask can deliver oxygen , it does not ensure the protection of the compromised airway in cases of inhalational injury. Inhalational burns can lead to airway edema and compromise , making definitive airway management necessary.</li><li>• While a well-fitting face mask can deliver oxygen , it does not ensure the protection of the compromised airway in cases of inhalational injury.</li><li>• well-fitting face mask can deliver oxygen</li><li>• Inhalational burns can lead to airway edema and compromise , making definitive airway management necessary.</li><li>• Inhalational burns</li><li>• airway edema and compromise</li><li>• Option C. Elective Cricothyroidotomy:</li><li>• Option C.</li><li>• Elective Cricothyroidotomy:</li><li>• Cricothyroidotomy involves creating an emergency airway through the cricothyroid membrane . While it can be a life-saving procedure , elective endotracheal intubation is preferred when feasible , as it provides a more secure airway and allows for controlled ventilation.</li><li>• Cricothyroidotomy involves creating an emergency airway through the cricothyroid membrane .</li><li>• Cricothyroidotomy</li><li>• creating an emergency airway through the cricothyroid membrane</li><li>• While it can be a life-saving procedure , elective endotracheal intubation is preferred when feasible , as it provides a more secure airway and allows for controlled ventilation.</li><li>• life-saving procedure</li><li>• elective endotracheal intubation</li><li>• feasible</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Early elective endotracheal intubation is important in inhalational burn injury to secure the airway , prevent complications , and ensure adequate ventilation within the critical timeframe of 4-5 hours.</li><li>➤ Early elective endotracheal intubation</li><li>➤ inhalational burn injury to secure the airway</li><li>➤ prevent complications</li><li>➤ adequate ventilation within the critical timeframe of 4-5 hours.</li><li>➤ Initial Management of the Burned Airway</li><li>➤ Initial Management of the Burned Airway</li><li>➤ Early elective intubation is safest Delay can make intubation very difficult because of swelling Be ready to perform an emergency cricothyroidotomy if intubation is delayed</li><li>➤ Early elective intubation is safest</li><li>➤ Delay can make intubation very difficult because of swelling</li><li>➤ Be ready to perform an emergency cricothyroidotomy if intubation is delayed</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition 673</li><li>➤ Ref :</li><li>➤ Bailey and Love’s short practice of surgery 28 th edition 673</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 30-year-old housewife accidentally spilled hot tea all over herself at a kitty party. She gets this lesion which is very painful and erythematous. Which layers of the skin are affected in this scenario?", "options": [{"label": "A", "text": "Epidermis", "correct": false}, {"label": "B", "text": "Epidermis + superficial dermis", "correct": true}, {"label": "C", "text": "Epidermis + whole dermis", "correct": false}, {"label": "D", "text": "Whole skin + connective tissue, muscle, bone", "correct": false}], "correct_answer": "B. Epidermis + superficial dermis", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/11/picture29_R8NNcVA.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/21/screenshot-2024-03-21-190816_B8rJV9A.png"], "explanation": "<p><strong>Ans. B) Epidermis + superficial dermis.</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Find the incorrect pair as per Jackson’s zones of tissue injury in burns:", "options": [{"label": "A", "text": "Zone of coagulation- most severely burned portion.", "correct": false}, {"label": "B", "text": "Zone of hyperemia- heals with minimal scarring.", "correct": false}, {"label": "C", "text": "Zone of stasis – has variable degree of vasoconstriction.", "correct": false}, {"label": "D", "text": "Zone of coagulation – at periphery of wound.", "correct": true}], "correct_answer": "D. Zone of coagulation – at periphery of wound.", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/11/picture31.jpg"], "explanation": "<p><strong>Ans. D) Zone of coagulation – at periphery of wound.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A : Zone of Coagulation - Most Severely Burned Portion:</li><li>• Option A</li><li>• Zone of Coagulation - Most Severely Burned Portion:</li><li>• This central zone experiences the most severe injury , leading to irreversible damage and necrosis. The tissues in this zone cannot be salvaged and typically undergo coagulative necrosis.</li><li>• This central zone experiences the most severe injury , leading to irreversible damage and necrosis.</li><li>• central zone</li><li>• most severe injury</li><li>• irreversible damage and necrosis.</li><li>• The tissues in this zone cannot be salvaged and typically undergo coagulative necrosis.</li><li>• Option B . Zone of Hyperaemia - Heals with Minimal Scarring:</li><li>• Option B</li><li>• Zone of Hyperaemia - Heals with Minimal Scarring:</li><li>• The outermost zone , characterized by increased blood flow and vasodilation. Injuries in this zone have the potential to heal with minimal or no scarring, even without intervention.</li><li>• The outermost zone , characterized by increased blood flow and vasodilation.</li><li>• outermost zone</li><li>• increased blood flow and vasodilation.</li><li>• Injuries in this zone have the potential to heal with minimal or no scarring, even without intervention.</li><li>• Option C . Zone of Stasis - Variable Degree of Vasoconstriction:</li><li>• Option C</li><li>• Zone of Stasis - Variable Degree of Vasoconstriction:</li><li>• Located between the zone of coagulation and hyperaemia . Experiences vasoconstriction and ischemia to varying degrees. Timely intervention can salvage tissues in this zone, preventing progression to irreversible damage.</li><li>• Located between the zone of coagulation and hyperaemia .</li><li>• between the zone of coagulation and hyperaemia</li><li>• Experiences vasoconstriction and ischemia to varying degrees.</li><li>• Timely intervention can salvage tissues in this zone, preventing progression to irreversible damage.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Understanding the correct spatial arrangement of Jackson's zones in burn injuries , with the zone of coagulation positioned centrally , zone of stasis in between , and the zone of hyperemia as the outermost region .</li><li>➤ correct spatial arrangement of Jackson's zones in burn injuries</li><li>➤ zone of coagulation positioned centrally</li><li>➤ zone of stasis in between</li><li>➤ zone of hyperemia as the outermost region</li><li>➤ Central zone - zone of coagulation-&gt; cannot be salvaged. Zone of stasis - variable degrees of vasoconstriction and ischemia-&gt; can be salvaged with timely intervention. Zone of hyperemia - outermost zone, heals with minimal or no scarring even without intervention.</li><li>➤ Central zone - zone of coagulation-&gt; cannot be salvaged.</li><li>➤ Central zone</li><li>➤ Zone of stasis - variable degrees of vasoconstriction and ischemia-&gt; can be salvaged with timely intervention.</li><li>➤ Zone of stasis</li><li>➤ Zone of hyperemia - outermost zone, heals with minimal or no scarring even without intervention.</li><li>➤ Zone of hyperemia</li><li>➤ Ref : Sabiston textbook of Surgery 20 th edition pg 506</li><li>➤ Ref :</li><li>➤ Sabiston textbook of Surgery 20 th edition pg 506</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-kg adult man has suffered from 40% second degree burns. How much fluid will be needed for resuscitation in first 8 hours as per Parkland’s equation?", "options": [{"label": "A", "text": "8 liters", "correct": false}, {"label": "B", "text": "4 liters", "correct": true}, {"label": "C", "text": "2 liters", "correct": false}, {"label": "D", "text": "6 liters", "correct": false}], "correct_answer": "B. 4 liters", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/11/picture32.jpg"], "explanation": "<p><strong>Ans. B) 4 liters</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Fluid resuscitation in burns</li><li>• Fluid resuscitation in burns</li><li>• As per Parkland formula total fluid to be given in a 50 kg man = 4 ml x 50kg x 40 %TBSA= 8 litres of this ½ is given in the first 8 hours so, 4 litres is given in the first 8 hours .</li><li>• Parkland formula total fluid to be given in a 50 kg man = 4 ml x 50kg x 40 %TBSA= 8</li><li>• litres of this ½ is given in the first 8 hours</li><li>• 4 litres is given in the first 8 hours</li><li>• Ref : Bailey and Love’s short practice of surgery 28 th edition pg 671</li><li>• Ref :</li><li>• Bailey and Love’s short practice of surgery 28 th edition pg 671</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these burns creams causes metabolic acidosis?", "options": [{"label": "A", "text": "Silver nitrate", "correct": false}, {"label": "B", "text": "Silver sulphadiazine", "correct": false}, {"label": "C", "text": "Mafenide acetate", "correct": true}, {"label": "D", "text": "Cerium nitrate", "correct": false}], "correct_answer": "C. Mafenide acetate", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Mafenide acetate</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A. Silver nitrate : It may cause skin discoloration but is not known for causing metabolic acidosis .</li><li>• Option A. Silver nitrate</li><li>• skin discoloration</li><li>• causing metabolic acidosis</li><li>• Option B. Silver sulphadiazine : Silver sulfadiazine is a commonly used burn cream that acts as a broad-spectrum antimicrobial agent with anti-pseudomonas actions . It does not cause metabolic acidosis.</li><li>• Option B. Silver sulphadiazine</li><li>• used burn cream that acts as a broad-spectrum antimicrobial agent</li><li>• anti-pseudomonas actions</li><li>• Option D. Cerium nitrate : Cerium nitrate is not related to metabolic acidosis, however it helps in improving local cell mediated immunity .</li><li>• Option D. Cerium nitrate</li><li>• not related to metabolic acidosis,</li><li>• helps in improving local cell mediated immunity</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Mafenide acetate , when applied to extensive burns , can lead to metabolic acidosis due to the liberation of carbon dioxide during its antimicrobial action . This is popular, especially in the USA, but is painful to apply. It is usually used as a 5% topical solution .</li><li>• Mafenide acetate</li><li>• applied to extensive burns</li><li>• metabolic acidosis due to the liberation of carbon dioxide</li><li>• antimicrobial action</li><li>• 5% topical solution</li><li>• Acticoat . This is a nanocrystalline silver barrier dressing and is an effective antimicrobial against a broad spectrum of bacteria.</li><li>• Acticoat . This is a nanocrystalline silver barrier dressing and is an effective antimicrobial against a broad spectrum of bacteria.</li><li>• Acticoat</li><li>• Ref : Bailey and Love’s short practice of surgery 28 th edition pg 674</li><li>• Ref :</li><li>• Bailey and Love’s short practice of surgery 28 th edition pg 674</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these burns’ patients would not require admission at a designated burns centre?", "options": [{"label": "A", "text": "Electrical burns", "correct": false}, {"label": "B", "text": "Partial thickness burns of 7% TBSA in an adult", "correct": true}, {"label": "C", "text": "Chemical burns", "correct": false}, {"label": "D", "text": "Inhalational injury", "correct": false}], "correct_answer": "B. Partial thickness burns of 7% TBSA in an adult", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Partial thickness burns of 7% TBSA</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Electrical burns : Electrical burns are referred to designated burn centers due to the potential for deep tissue injury and internal damage , which may not be evident initially.</li><li>• Option A. Electrical burns</li><li>• designated burn centers due to the potential for deep tissue injury and internal damage</li><li>• Option C. Chemical burns : Chemical burns are referred to designated burn centers due to the potential for extensive tissue damage and complications.</li><li>• Option C. Chemical burns</li><li>• designated burn centers due to the potential for extensive tissue damage</li><li>• Option D. Inhalational injury : Inhalational injuries, including burns affecting the airway, are referred to designated burn centers for specialized respiratory care.</li><li>• Option D. Inhalational injury</li><li>• burns affecting the airway,</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Partial thickness burns involving more than 10% TBSA warrant referral to a designated burn center for comprehensive management.</li><li>• Partial thickness burns</li><li>• more than 10% TBSA warrant</li><li>• burn center for comprehensive management.</li><li>• PATIENTS WITH THE FOLLOWING CRITERIA ARE REFERRED TO DESIGNATED BURN CENTER</li><li>• PATIENTS WITH THE FOLLOWING CRITERIA ARE REFERRED TO</li><li>• DESIGNATED BURN CENTER</li><li>• Partial-thickness burns&gt;10% TBSA Burns involving the face, hands, feet, genitalia, perineum or major joints Any full-thickness burn Electrical burns, including lightning injury Chemical burns Inhalation injury Burns in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect outcome Any patient with burns and concomitant trauma (e.g., fractures) in which the burn injury poses the greater immediate risk for morbidity and mortality Burned children in hospitals without qualified personnel or equipment to care for children Burns in patients who will require social, emotional, or long-term rehabilitative intervention</li><li>• Partial-thickness burns&gt;10% TBSA</li><li>• Burns involving the face, hands, feet, genitalia, perineum or major joints</li><li>• Any full-thickness burn</li><li>• Electrical burns, including lightning injury</li><li>• Chemical burns</li><li>• Inhalation injury</li><li>• Burns in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect outcome</li><li>• Any patient with burns and concomitant trauma (e.g., fractures) in which the burn injury poses the greater immediate risk for morbidity and mortality</li><li>• Burned children in hospitals without qualified personnel or equipment to care for children</li><li>• Burns in patients who will require social, emotional, or long-term rehabilitative intervention</li><li>• Ref : Bailey and Love’s short practice of surgery 28 th edition pg 666</li><li>• Ref :</li><li>• Bailey and Love’s short practice of surgery 28 th edition pg 666</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old scientist while working in the laboratory accidentally pours chemical (hydrofluoric acid) over his right hand. What is the mainstay in management of this chemical burn?", "options": [{"label": "A", "text": "Irrigation of burns site", "correct": false}, {"label": "B", "text": "Topical application of calcium gluconate gel", "correct": true}, {"label": "C", "text": "Intra-arterial injection of calcium gluconate", "correct": false}, {"label": "D", "text": "Bier’s block", "correct": false}], "correct_answer": "B. Topical application of calcium gluconate gel", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Topical application of calcium gluconate gel</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Irrigation of burn site : While irrigation is important for chemical burns, the specific nature of hydrofluoric acid burns requires additional measures beyond irrigation.</li><li>• Option A. Irrigation of burn site</li><li>• chemical burns, the specific nature of hydrofluoric acid burns</li><li>• Option C. Intra-arterial injection of calcium gluconate : This option is not a standard or recommended method for managing hydrofluoric acid burns . Topical application is the primary approach.</li><li>• Option C. Intra-arterial injection of calcium gluconate</li><li>• not a standard or recommended method for managing hydrofluoric acid burns</li><li>• Option D. Bier’s block : Bier's block may be considered for severe burns or burns to large areas of the hand , but it is not the mainstay of management.</li><li>• Option D. Bier’s block</li><li>• severe burns or burns to large areas of the hand</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Understanding the specific management approach for hydrofluoric acid burns , which involves the topical application of calcium gluconate gel to counteract the chelating effects on calcium in tissues.</li><li>• specific management approach for hydrofluoric acid burns</li><li>• topical application of calcium gluconate gel</li><li>• counteract the chelating effects on calcium in tissues.</li><li>• Management of chemical burns:</li><li>• Management of chemical burns:</li><li>• Damage is from corrosive acid poisoning Copious lavage with water helps in most cases In chemical powders, initially brush it off before washing</li><li>• Damage is from corrosive acid poisoning</li><li>• Copious lavage with water helps in most cases</li><li>• In chemical powders, initially brush it off before washing</li><li>• Management of hydrofluoric acid burns:</li><li>• Management of hydrofluoric acid burns:</li><li>• One acid that is a common cause of acid burns is hydrofluoric acid, although generally a weak acid, it chelates calcium and magnesium in tissues. The initial management is with calcium gluconate gel topically; however, severe burns or burns to large areas of the hand can be subsequently treated with Bier’s blocks containing calcium gluconate 10% gel.</li><li>• One acid that is a common cause of acid burns is hydrofluoric acid, although generally a weak acid, it chelates calcium and magnesium in tissues.</li><li>• The initial management is with calcium gluconate gel topically; however, severe burns or burns to large areas of the hand can be subsequently treated with Bier’s blocks containing calcium gluconate 10% gel.</li><li>• Ref : Bailey and Love’s short practice of surgery 28 th edition pg 680</li><li>• Ref :</li><li>• Bailey and Love’s short practice of surgery 28 th edition pg 680</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "As a part of resuscitation of patient with 40% total burns surface area (TBSA), what would be the fluid of choice in an adult in the first 24 hours?", "options": [{"label": "A", "text": "Dextrose Normal Saline", "correct": false}, {"label": "B", "text": "Human albumin", "correct": false}, {"label": "C", "text": "Ringer lactate", "correct": true}, {"label": "D", "text": "Normal saline", "correct": false}], "correct_answer": "C. Ringer lactate", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Ringer lactate</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A. Dextrose Normal Saline : While it provides glucose and saline , it may not be the fluid of choice for extensive resuscitation due to its composition.</li><li>• Option A. Dextrose Normal Saline</li><li>• provides glucose and saline</li><li>• Option B. Human albumin : Colloids like human albumin can be used but are expensive and may leak out of capillaries in the first 12 hours.</li><li>• Option B. Human albumin</li><li>• Colloids like human albumin</li><li>• used but are expensive</li><li>• Option D. Normal saline : Normal saline can cause hyperchloremic metabolic acidosis , making it less ideal for extensive resuscitation.</li><li>• Option D. Normal saline</li><li>• cause hyperchloremic metabolic acidosis</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Hartmann’s solution or Ringer’s lactate is the most commonly used crystalloid as it most closely replicates the osmolality of plasma . It is considerably less expensive than colloid and can maintain intravascular volume.</li><li>• Hartmann’s solution or Ringer’s lactate is the most commonly used crystalloid</li><li>• closely replicates the osmolality of plasma</li><li>• Crystalloid resuscitation requires eight-fold greater volumes than colloid which can result in increased tissue oedema .</li><li>• Crystalloid resuscitation</li><li>• eight-fold greater volumes</li><li>• colloid</li><li>• increased tissue oedema</li><li>• Normal saline - Causes hyperchloremic metabolic acidosis</li><li>• Normal saline</li><li>• Colloid - Can be used but is expensive and leaks out of capillaries in first 12 hours.</li><li>• Colloid</li><li>• Ref : Bailey and Love’s short practice of surgery 28 th edition pg 671</li><li>• Ref :</li><li>• Bailey and Love’s short practice of surgery 28 th edition pg 671</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 35-year-old housewife suffers from burns due to explosion of gas cylinder in the kitchen. Her both upper limbs are charred along with head, face and neck. Calculate the %TBSA:", "options": [{"label": "A", "text": "9%", "correct": false}, {"label": "B", "text": "18%", "correct": false}, {"label": "C", "text": "27%", "correct": true}, {"label": "D", "text": "36%", "correct": false}], "correct_answer": "C. 27%", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/23/01-2.jpg"], "explanation": "<p><strong>Ans. C) 27%</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• According to Wallace’s rule in an adult,</li><li>• According to Wallace’s rule in an adult,</li><li>• Each upper limb – 9% (total 18% for both upper limbs)</li><li>• upper limb – 9%</li><li>• Head, face and neck -9%</li><li>• Head, face and neck -9%</li><li>• Total burns area (%TBSA) = 27%</li><li>• Total burns area</li><li>• 27%</li><li>• Ref : Bailey and Love’s short practice of surgery 28 th edition pg 668</li><li>• Ref :</li><li>• Bailey and Love’s short practice of surgery 28 th edition pg 668</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the cardiovascular system change that DOES NOT happen in a patient of burns:", "options": [{"label": "A", "text": "Increased capillary permeability", "correct": false}, {"label": "B", "text": "Peripheral vasodilation", "correct": true}, {"label": "C", "text": "Decreased venous return", "correct": false}, {"label": "D", "text": "Decreased cardiac output", "correct": false}], "correct_answer": "B. Peripheral vasodilation", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/11/picture34.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/11/picture35.jpg"], "explanation": "<p><strong>Ans. B) Peripheral vasodilation</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Increased capillary permeability : Burns can lead to increased capillary permeability, causing fluid shift and edema .</li><li>• Option A. Increased capillary permeability</li><li>• causing fluid shift and edema</li><li>• Option C. Decreased venous return : Burns can lead to hypovolemia and decreased venous return to the heart.</li><li>• Option C. Decreased venous return</li><li>• Burns can lead to hypovolemia</li><li>• Option D. Decreased cardiac output: Due to factors like hypovolemia and decreased venous return , cardiac output may decrease in burn patients.</li><li>• Option D. Decreased cardiac output:</li><li>• hypovolemia and decreased venous return</li><li>• cardiac output may decrease in burn patients.</li><li>• Educational objective :</li><li>• Educational objective</li><li>• The cardiovascular changes in burn patients includes increased capillary permeability , decreased venous return , and potential decrease in cardiac output .</li><li>• cardiovascular changes in burn patients</li><li>• increased capillary permeability</li><li>• decreased venous return</li><li>• potential decrease in cardiac output</li><li>• CVS changes in burns:</li><li>• Overall changes in burns:</li><li>• Ref : Bailey and Love’s short practice of surgery 28 th edition pg 665-668</li><li>• Ref :</li><li>• Bailey and Love’s short practice of surgery 28 th edition pg 665-668</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In children with burns, maintenance IV fluid normally given is?", "options": [{"label": "A", "text": "Ringer lactate", "correct": false}, {"label": "B", "text": "5% dextrose", "correct": false}, {"label": "C", "text": "Normal saline", "correct": false}, {"label": "D", "text": "Dextrose saline", "correct": true}], "correct_answer": "D. Dextrose saline", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Dextrose saline.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• In children with burns maintenance fluid preferred is dextrose - saline given as follows:</li><li>• children with burns maintenance fluid preferred is dextrose -</li><li>• 100 mL/kg for 24 hours for the first 10 kg. 50 mL/kg for the next 10 kg. 20 mL/kg for 24 hours for each kilogram over 20 kg body weight.</li><li>• 100 mL/kg for 24 hours for the first 10 kg.</li><li>• 50 mL/kg for the next 10 kg.</li><li>• 20 mL/kg for 24 hours for each kilogram over 20 kg body weight.</li><li>• Ref : Bailey and Love’s short practice of surgery 28 th edition pg 671</li><li>• Ref :</li><li>• Bailey and Love’s short practice of surgery 28 th edition pg 671</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which layer is involved in blister formation in a superficial partial thickness burn?", "options": [{"label": "A", "text": "Epidermis", "correct": false}, {"label": "B", "text": "Papillary dermis", "correct": true}, {"label": "C", "text": "Reticular dermis", "correct": false}, {"label": "D", "text": "Entire dermis", "correct": false}], "correct_answer": "B. Papillary dermis", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B)</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is not a feature of suspected inhalational injury?", "options": [{"label": "A", "text": "Burned nasal hair", "correct": false}, {"label": "B", "text": "Burns over face and neck", "correct": false}, {"label": "C", "text": "Burns while bathing", "correct": true}, {"label": "D", "text": "Stridor", "correct": false}], "correct_answer": "C. Burns while bathing", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Burns while bathing</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A . Burned nasal hair : Singeing of facial and nasal hair is a warning sign of inhalational injury due to exposure to hot air or smoke .</li><li>• Option A</li><li>• Burned nasal hair</li><li>• Singeing of facial and nasal hair</li><li>• warning sign of inhalational injury</li><li>• exposure to hot air or smoke</li><li>• Option B . Burns over face and neck : Burns in these areas are indicative of potential inhalational injury as the airway is exposed to harmful substances during a fire .</li><li>• Option B</li><li>• Burns over face and neck</li><li>• indicative of potential inhalational injury as the airway</li><li>• harmful substances during a fire</li><li>• Option D. Stridor : Stridor, a high-pitched sound during breathing , is a warning sign of airway obstruction and inhalational injury.</li><li>• Option D. Stridor</li><li>• high-pitched sound during breathing</li><li>• warning sign of airway obstruction</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Warning signs of burns to the respiratory system:</li><li>• Warning signs of burns to the respiratory system:</li><li>• Burns around the face and neck, blistering inside the mouth A history of being trapped in an enclosed space Change to/hoarseness of voice Stridor Singeing of facial and nasal hair</li><li>• Burns around the face and neck, blistering inside the mouth</li><li>• A history of being trapped in an enclosed space</li><li>• Change to/hoarseness of voice</li><li>• Stridor</li><li>• Singeing of facial and nasal hair</li><li>• Ref : Bailey 28 th Ed. Pg 665</li><li>• Ref : Bailey 28 th Ed. Pg 665</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Hypovolemic shock can occur if total burns surface area exceeds?", "options": [{"label": "A", "text": "15%", "correct": true}, {"label": "B", "text": "25%", "correct": false}, {"label": "C", "text": "40%", "correct": false}, {"label": "D", "text": "50%", "correct": false}], "correct_answer": "A. 15%", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) 15%</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• The shock reaction after burns:</li><li>• The shock reaction after burns:</li><li>• Burns produce an inflammatory reaction. This leads to vastly increased vascular permeability. Water, solutes, and proteins move from the intra- to the extravascular space. The volume of fluid lost is directly proportional to the area of the burn. Above 15% of surface area, the loss of fluid produces shock requiring resuscitation.</li><li>• Burns produce an inflammatory reaction.</li><li>• This leads to vastly increased vascular permeability.</li><li>• vastly increased vascular permeability.</li><li>• Water, solutes, and proteins move from the intra- to the extravascular space.</li><li>• The volume of fluid lost is directly proportional to the area of the burn.</li><li>• Above 15% of surface area, the loss of fluid produces shock requiring resuscitation.</li><li>• Above 15% of surface area, the loss of fluid produces shock requiring resuscitation.</li><li>• Ref : Bailey 28 th Ed. Pg 665</li><li>• Ref</li><li>• : Bailey 28 th Ed. Pg 665</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "As per Lund and Browder charts, which of these areas is not affected by age during calculation of %TBSA in children?", "options": [{"label": "A", "text": "Leg", "correct": false}, {"label": "B", "text": "Thigh", "correct": false}, {"label": "C", "text": "Head", "correct": false}, {"label": "D", "text": "Arm", "correct": true}], "correct_answer": "D. Arm", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/11/picture37.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/22/screenshot-2024-03-22-095919.png"], "explanation": "<p><strong>Ans. D) Arm</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is the most common type of malignant melanoma?", "options": [{"label": "A", "text": "Superficial spreading", "correct": true}, {"label": "B", "text": "Nodular", "correct": false}, {"label": "C", "text": "Lentigo maligna", "correct": false}, {"label": "D", "text": "Acral", "correct": false}], "correct_answer": "A. Superficial spreading", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Superficial spreading</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}]; if (!Array.isArray(questions) || questions.length === 0) { throw new Error("Questions data is empty or invalid"); } debugLog(`Successfully parsed ${questions.length} questions`); } catch (e) { console.error("Failed to parse questions_json:", e); document.getElementById('error-message').innerHTML = "Error loading quiz data. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('start-test').disabled = true; // Fallback to sample questions for testing questions = [ { text: "What is 2 + 2?", options: [ { label: "A", text: "3", correct: false }, { label: "B", text: "4", correct: true }, { label: "C", text: "5", correct: false }, { label: "D", text: "6", correct: false } ], correct_answer: "B. 4", question_images: [], explanation_images: [], explanation: "<p>2 + 2 = 4</p><p>@dams_new_robot</p>", bot: "@dams_new_robot", audio: "", video: "" } ]; debugLog("Loaded fallback questions"); } // Quiz state let currentQuestion = 0; let answers = new Array(questions.length).fill(null); let markedForReview = new Array(questions.length).fill(false); let timeRemaining = 52 * 60; // Duration in seconds let timerInterval = null; const quizId = `{title.replace(/\s+/g, '_').toLowerCase()}`; // Unique ID for local storage // Load saved progress function loadProgress() { try { debugLog("Loading progress from localStorage"); const saved = localStorage.getItem(`quiz_${quizId}`); if (saved) { const { savedAnswers, savedMarked, savedTime } = JSON.parse(saved); answers = savedAnswers || answers; markedForReview = savedMarked || markedForReview; timeRemaining = savedTime !== undefined ? savedTime : timeRemaining; debugLog("Progress loaded successfully"); } else { debugLog("No saved progress found"); } } catch (e) { console.error("Error loading progress:", e); debugLog("Failed to load progress: " + e.message); } } // Save progress function saveProgress() { try { debugLog("Saving progress to localStorage"); localStorage.setItem(`quiz_${quizId}`, JSON.stringify({ savedAnswers: answers, savedMarked: markedForReview, savedTime: timeRemaining })); debugLog("Progress saved successfully"); } catch (e) { console.error("Error saving progress:", e); debugLog("Failed to save progress: " + e.message); } } // Initialize quiz function initQuiz() { try { debugLog("Initializing quiz"); loadProgress(); const startButton = document.getElementById('start-test'); if (!startButton) { throw new Error("Start test button not found"); } startButton.addEventListener('click', startQuiz); debugLog("Start test button listener attached"); document.getElementById('previous-btn').addEventListener('click', showPreviousQuestion); document.getElementById('next-btn').addEventListener('click', showNextQuestion); document.getElementById('mark-review').addEventListener('click', toggleMarkForReview); document.getElementById('nav-toggle').addEventListener('click', toggleNavPanel); document.getElementById('submit-test').addEventListener('click', showSubmitModal); document.getElementById('continue-test').addEventListener('click', closeExitModal); document.getElementById('exit-test').addEventListener('click', () => { debugLog("Exiting test"); localStorage.removeItem(`quiz_${quizId}`); window.location.reload(); }); document.getElementById('cancel-submit').addEventListener('click', closeSubmitModal); document.getElementById('confirm-submit').addEventListener('click', submitTest); document.getElementById('take-again').addEventListener('click', () => { debugLog("Restarting test"); localStorage.removeItem(`quiz_${quizId}`); window.location.reload(); }); document.getElementById('review-test').addEventListener('click', () => showResults(currentResultQuestion)); document.getElementById('close-nav').addEventListener('click', toggleNavPanel); document.getElementById('theme-toggle').addEventListener('click', toggleTheme); document.getElementById('nav-filter').addEventListener('change', updateNavPanel); document.getElementById('prev-result').addEventListener('click', showPreviousResult); document.getElementById('next-result').addEventListener('click', showNextResult); document.getElementById('results-nav-toggle').addEventListener('click', toggleResultsNavPanel); document.getElementById('close-results-nav').addEventListener('click', toggleResultsNavPanel); document.getElementById('results-nav-filter').addEventListener('change', updateResultsNavPanel); debugLog("Quiz initialized successfully"); } catch (e) { console.error("Failed to initialize quiz:", e); debugLog("Failed to initialize quiz: " + e.message); document.getElementById('error-message').innerHTML = "Error initializing quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('start-test').disabled = true; } } // Start quiz function startQuiz() { try { debugLog("Starting quiz"); document.getElementById('instructions').classList.add('hidden'); document.getElementById('quiz').classList.remove('hidden'); showQuestion(currentQuestion); startTimer(); updateNavPanel(); debugLog("Quiz started successfully"); } catch (e) { console.error("Error starting quiz:", e); debugLog("Failed to start quiz: " + e.message); document.getElementById('error-message').innerHTML = "Error starting quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('quiz').classList.add('hidden'); document.getElementById('instructions').classList.remove('hidden'); } } // Show question function showQuestion(index) { try { debugLog(`Showing question ${index + 1}`); currentQuestion = index; const q = questions[index]; if (!q) { throw new Error(`Question ${index} is undefined`); } document.getElementById('question-number').innerHTML = `Question <span>${index + 1}</span> of ${questions.length}`; document.getElementById('question-text').innerHTML = q.text || "No question text available"; const imagesDiv = document.getElementById('question-images'); imagesDiv.innerHTML = q.question_images && q.question_images.length > 0 ? q.question_images.map(url => `<img src="${url}" alt="Question Image" class="max-w-full h-auto rounded-lg">`).join('') : ''; const optionsDiv = document.getElementById('options'); optionsDiv.innerHTML = q.options && q.options.length > 0 ? q.options.map(opt => ` <button class="option-btn w-full text-left p-3 border rounded-lg ${answers[index] === opt.label ? 'selected' : ''}" onclick="selectOption(${index}, '${opt.label}')" aria-label="Option ${opt.label}: ${opt.text}"> ${opt.label}. ${opt.text} </button> `).join('') : '<p class="text-red-500">No options available</p>'; document.getElementById('previous-btn').disabled = index === 0; document.getElementById('next-btn').disabled = index === questions.length - 1; document.getElementById('mark-review').classList.toggle('marked', markedForReview[index]); updateProgressBar(); saveProgress(); window.scrollTo({ top: 0, behavior: 'smooth' }); debugLog(`Question ${index + 1} displayed successfully`); } catch (e) { console.error("Error displaying question:", e); debugLog("Failed to display question: " + e.message); } } // Select option function selectOption(index, label) { try { debugLog(`Selecting option ${label} for question ${index + 1}`); answers[index] = label; const optionsDiv = document.getElementById('options'); const optionButtons = optionsDiv.querySelectorAll('.option-btn'); optionButtons.forEach(btn => { const btnLabel = btn.textContent.trim().split('.')[0]; btn.classList.toggle('selected', btnLabel === label); }); updateNavPanel(); saveProgress(); debugLog(`Option ${label} selected for question ${index + 1}`); } catch (e) { console.error("Error selecting option:", e); debugLog("Failed to select option: " + e.message); } } // Toggle mark for review function toggleMarkForReview() { try { debugLog(`Toggling mark for review on question ${currentQuestion + 1}`); markedForReview[currentQuestion] = !markedForReview[currentQuestion]; document.getElementById('mark-review').classList.toggle('marked', markedForReview[currentQuestion]); updateNavPanel(); saveProgress(); debugLog(`Mark for review toggled for question ${currentQuestion + 1}`); } catch (e) { console.error("Error marking for review:", e); debugLog("Failed to mark for review: " + e.message); } } // Navigate to previous question function showPreviousQuestion() { try { debugLog(`Navigating to previous question from ${currentQuestion + 1}`); if (currentQuestion > 0) { currentQuestion--; showQuestion(currentQuestion); } } catch (e) { console.error("Error navigating to previous question:", e); debugLog("Failed to navigate to previous question: " + e.message); } } // Navigate to next question function showNextQuestion() { try { debugLog(`Navigating to next question from ${currentQuestion + 1}`); if (currentQuestion < questions.length - 1) { currentQuestion++; showQuestion(currentQuestion); } } catch (e) { console.error("Error navigating to next question:", e); debugLog("Failed to navigate to next question: " + e.message); } } // Handle question navigation click function handleQuestionNavClick(index) { try { debugLog(`Navigating to question ${index + 1} via nav panel`); showQuestion(index); toggleNavPanel(); } catch (e) { console.error("Error handling navigation click:", e); debugLog("Failed to navigate via nav panel: " + e.message); } } // Start timer function startTimer() { try { debugLog("Starting timer"); timerInterval = setInterval(() => { if (timeRemaining <= 0) { debugLog("Timer expired, submitting test"); clearInterval(timerInterval); submitTest(); } else { timeRemaining--; const minutes = Math.floor(timeRemaining / 60); const seconds = timeRemaining % 60; document.getElementById('timer').innerHTML = `Time Remaining: <span>${minutes.toString().padStart(2, '0')}:${seconds.toString().padStart(2, '0')}</span>`; saveProgress(); } }, 1000); debugLog("Timer started successfully"); } catch (e) { console.error("Error starting timer:", e); debugLog("Failed to start timer: " + e.message); } } // Update progress bar function updateProgressBar() { try { debugLog("Updating progress bar"); const progress = ((currentQuestion + 1) / questions.length) * 100; document.getElementById('progress-bar').style.width = `${progress}%`; debugLog("Progress bar updated"); } catch (e) { console.error("Error updating progress bar:", e); debugLog("Failed to update progress bar: " + e.message); } } // Update quiz navigation panel function updateNavPanel() { try { debugLog("Updating quiz navigation panel"); const filter = document.getElementById('nav-filter').value; const navGrid = document.getElementById('nav-grid'); navGrid.innerHTML = questions.map((_, i) => { if (filter === 'answered' && !answers[i]) return ''; if (filter === 'unanswered' && answers[i]) return ''; if (filter === 'marked' && !markedForReview[i]) return ''; return ` <button class="question-nav-btn ${answers[i] ? 'answered' : 'unanswered'} ${markedForReview[i] ? 'marked-nav' : ''}" onclick="handleQuestionNavClick(${i})" aria-label="Go to Question ${i + 1}"> ${i + 1} </button> `; }).join(''); debugLog("Quiz navigation panel updated"); } catch (e) { console.error("Error updating quiz navigation panel:", e); debugLog("Failed to update quiz navigation panel: " + e.message); } } // Update results navigation panel function updateResultsNavPanel() { try { debugLog("Updating results navigation panel"); const filter = document.getElementById('results-nav-filter').value; const navGrid = document.getElementById('results-nav-grid'); navGrid.innerHTML = questions.map((_, i) => { if (filter === 'answered' && !answers[i]) return ''; if (filter === 'unanswered' && answers[i]) return ''; if (filter === 'marked' && !markedForReview[i]) return ''; return ` <button class="result-nav-btn-grid ${answers[i] ? 'answered' : 'unanswered'} ${markedForReview[i] ? 'marked-nav' : ''}" onclick="handleResultNavClick(${i})" aria-label="Go to Result for Question ${i + 1}"> ${i + 1} </button> `; }).join(''); debugLog("Results navigation panel updated"); } catch (e) { console.error("Error updating results navigation panel:", e); debugLog("Failed to update results navigation panel: " + e.message); } } // Toggle quiz navigation panel function toggleNavPanel() { try { debugLog("Toggling quiz navigation panel"); const navPanel = document.getElementById('nav-panel'); navPanel.classList.toggle('hidden'); debugLog("Quiz navigation panel toggled"); } catch (e) { console.error("Error toggling quiz navigation panel:", e); debugLog("Failed to toggle quiz navigation panel: " + e.message); } } // Toggle results navigation panel function toggleResultsNavPanel() { try { debugLog("Toggling results navigation panel"); const resultsNavPanel = document.getElementById('results-nav-panel'); resultsNavPanel.classList.toggle('hidden'); if (!resultsNavPanel.classList.contains('hidden')) { updateResultsNavPanel(); } debugLog("Results navigation panel toggled"); } catch (e) { console.error("Error toggling results navigation panel:", e); debugLog("Failed to toggle results navigation panel: " + e.message); } } // Handle result navigation click function handleResultNavClick(index) { try { debugLog(`Navigating to result for question ${index + 1} via nav panel`); showResults(index); toggleResultsNavPanel(); } catch (e) { console.error("Error handling result navigation click:", e); debugLog("Failed to navigate to result: " + e.message); } } // Show submit modal function showSubmitModal() { try { debugLog("Showing submit modal"); const attempted = answers.filter(a => a !== null).length; document.getElementById('attempted-count').textContent = attempted; document.getElementById('unattempted-count').textContent = questions.length - attempted; document.getElementById('submit-modal').classList.remove('hidden'); debugLog("Submit modal displayed"); } catch (e) { console.error("Error showing submit modal:", e); debugLog("Failed to show submit modal: " + e.message); } } // Close submit modal function closeSubmitModal() { try { debugLog("Closing submit modal"); document.getElementById('submit-modal').classList.add('hidden'); debugLog("Submit modal closed"); } catch (e) { console.error("Error closing submit modal:", e); debugLog("Failed to close submit modal: " + e.message); } } // Close exit modal function closeExitModal() { try { debugLog("Closing exit modal"); document.getElementById('exit-modal').classList.add('hidden'); debugLog("Exit modal closed"); } catch (e) { console.error("Error closing exit modal:", e); debugLog("Failed to close exit modal: " + e.message); } } // Submit test function submitTest() { try { debugLog("Submitting test"); clearInterval(timerInterval); document.getElementById('quiz').classList.add('hidden'); document.getElementById('submit-modal').classList.add('hidden'); document.getElementById('results').classList.remove('hidden'); showResults(0); // Start with first question // Trigger confetti animation confetti({ particleCount: 100, spread: 70, origin: { y: 0.6 } }); localStorage.removeItem(`quiz_${quizId}`); debugLog("Test submitted successfully"); } catch (e) { console.error("Error submitting test:", e); debugLog("Failed to submit test: " + e.message); } } // Show result for a single question function showResults(index) { try { debugLog(`Showing result for question ${index + 1}`); currentResultQuestion = index; let correct = 0, wrong = 0, unanswered = 0, marked = 0; answers.forEach((answer, i) => { const isCorrect = answer && questions[i].options.find(opt => opt.label === answer)?.correct; if (answer === null) unanswered++; else if (isCorrect) correct++; else wrong++; if (markedForReview[i]) marked++; }); const q = questions[index]; if (!q) { throw new Error(`Question ${index} is undefined`); } const userAnswer = answers[index]; const isCorrect = userAnswer && q.options.find(opt => opt.label === userAnswer)?.correct; const resultsContent = document.getElementById('results-content'); resultsContent.innerHTML = ` <div class="border p-4 rounded-lg ${isCorrect ? 'bg-green-50' : userAnswer ? 'bg-red-50' : 'bg-gray-50'}"> <p class="font-semibold">Question ${index + 1}: ${q.text || 'No question text'}</p> ${q.question_images && q.question_images.length > 0 ? q.question_images.map(url => `<img src="${url}" alt="Question Image" class="max-w-full h-auto rounded-lg my-2">`).join('') : ''} <p><strong>Your Answer:</strong> ${userAnswer ? `${userAnswer}. ${q.options.find(opt => opt.label === userAnswer)?.text || 'Invalid option'}` : 'Unanswered'}</p> <p><strong>Correct Answer:</strong> ${q.correct_answer || 'Unknown'}</p> <div class="mt-2">${q.explanation || 'No explanation available'}</div> ${q.explanation_images && q.explanation_images.length > 0 ? q.explanation_images.map(url => `<img src="${url}" alt="Explanation Image" class="max-w-full h-auto rounded-lg my-2">`).join('') : ''} ${q.video ? ` <button class="play-video bg-blue-500 text-white px-4 py-2 rounded-lg mt-2" onclick="loadVideo(this, '${q.video}', 'video-${index}')" aria-label="Play explanation video for Question ${index + 1}"> Play Video Explanation </button> <div id="video-${index}" class="video-container mt-2"></div> ` : '<p class="text-gray-500 mt-2">No video available</p>'} ${q.audio ? ` <button class="play-audio bg-blue-500 text-white px-4 py-2 rounded-lg mt-2" onclick="loadAudio(this, '${q.audio}', 'audio-${index}')" aria-label="Play audio explanation for Question ${index + 1}"> Play Audio Explanation </button> <div id="audio-${index}" class="audio-container mt-2"></div> ` : ''} </div> `; document.getElementById('correct-count').textContent = correct; document.getElementById('wrong-count').textContent = wrong; document.getElementById('unanswered-count').textContent = unanswered; document.getElementById('marked-count').textContent = marked; document.getElementById('result-question-number').innerHTML = `Question <span>${index + 1}</span> of ${questions.length}`; document.getElementById('prev-result').disabled = index === 0; document.getElementById('next-result').disabled = index === questions.length - 1; updateResultsNavPanel(); window.scrollTo({ top: 0, behavior: 'smooth' }); debugLog(`Result for question ${index + 1} displayed successfully`); } catch (e) { console.error("Error displaying result:", e); debugLog("Failed to display result: " + e.message); } } // Navigate to previous result function showPreviousResult() { try { debugLog(`Navigating to previous result from question ${currentResultQuestion + 1}`); if (currentResultQuestion > 0) { showResults(currentResultQuestion - 1); } } catch (e) { console.error("Error navigating to previous result:", e); debugLog("Failed to navigate to previous result: " + e.message); } } // Navigate to next result function showNextResult() { try { debugLog(`Navigating to next result from question ${currentResultQuestion + 1}`); if (currentResultQuestion < questions.length - 1) { showResults(currentResultQuestion + 1); } } catch (e) { console.error("Error navigating to next result:", e); debugLog("Failed to navigate to next result: " + e.message); } } // Lazy-load video function loadVideo(button, videoUrl, containerId) { try { debugLog(`Loading video for ${containerId}: ${videoUrl}`); if (!videoUrl) { const container = document.getElementById(containerId); container.innerHTML = `<p class="text-gray-500">No video available</p>`; button.remove(); debugLog("No video URL provided"); return; } const container = document.getElementById(containerId); container.innerHTML = ` <div class="video-loading"></div> <video controls class="w-full max-w-[600px] rounded-lg" preload="metadata" aria-label="Video explanation"> <source src="${videoUrl}" type="${videoUrl.endsWith('.m3u8') ? 'application/x-mpegURL' : 'video/mp4'}"> Your browser does not support the video tag. </video> `; container.classList.add('active'); button.remove(); // Initialize HLS.js for .m3u8 videos const video = container.querySelector('video'); if (videoUrl.endsWith('.m3u8') && Hls.isSupported()) { const hls = new Hls(); hls.loadSource(videoUrl); hls.attachMedia(video); hls.on(Hls.Events.ERROR, (event, data) => { console.error("HLS.js error:", data); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; debugLog("HLS.js error: " + JSON.stringify(data)); }); } else if (videoUrl.endsWith('.m3u8') && video.canPlayType('application/vnd.apple.mpegurl')) { video.src = videoUrl; } // Handle video load errors video.onerror = () => { console.error("Video load error for URL:", videoUrl); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; debugLog("Video load error for URL: " + videoUrl); }; // Remove loading spinner when video is ready video.onloadedmetadata = () => { container.querySelector('.video-loading').remove(); debugLog("Video loaded successfully"); }; } catch (e) { console.error("Error loading video:", e); debugLog("Failed to load video: " + e.message); const container = document.getElementById(containerId); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; } } // Lazy-load audio function loadAudio(button, audioUrl, containerId) { try { debugLog(`Loading audio for ${containerId}: ${audioUrl}`); if (!audioUrl) { const container = document.getElementById(containerId); container.innerHTML = `<p class="text-gray-500">No audio available</p>`; button.remove(); debugLog("No audio URL provided"); return; } const container = document.getElementById(containerId); container.innerHTML = ` <audio controls class="w-full max-w-[600px]" preload="metadata" aria-label="Audio explanation"> <source src="${audioUrl}" type="audio/mpeg"> Your browser does not support the audio tag. </audio> `; container.classList.add('active'); button.remove(); // Handle audio load errors const audio = container.querySelector('audio'); audio.onerror = () => { console.error("Audio load error for URL:", audioUrl); container.innerHTML = `<p class="text-red-500">Error loading audio. <a href="${audioUrl}" target="_blank" aria-label="Open audio in new tab">Open audio</a></p>`; debugLog("Audio load error for URL: " + audioUrl); }; debugLog("Audio loaded successfully"); } catch (e) { console.error("Error loading audio:", e); debugLog("Failed to load audio: " + e.message); const container = document.getElementById(containerId); container.innerHTML = `<p class="text-red-500">Error loading audio. <a href="${audioUrl}" target="_blank" aria-label="Open audio in new tab">Open audio</a></p>`; } } // Toggle dark mode function toggleTheme() { try { debugLog("Toggling theme"); document.documentElement.classList.toggle('dark'); localStorage.setItem('theme', document.documentElement.classList.contains('dark') ? 'dark' : 'light'); debugLog("Theme toggled successfully"); } catch (e) { console.error("Error toggling theme:", e); debugLog("Failed to toggle theme: " + e.message); } } // Load theme preference function loadTheme() { try { debugLog("Loading theme preference"); const theme = localStorage.getItem('theme'); if (theme === 'dark') { document.documentElement.classList.add('dark'); } debugLog("Theme loaded successfully"); } catch (e) { console.error("Error loading theme:", e); debugLog("Failed to load theme: " + e.message); } } // Initialize on DOM content loaded window.addEventListener('DOMContentLoaded', () => { try { debugLog("DOM content loaded, initializing quiz"); loadTheme(); initQuiz(); } catch (e) { console.error("Error during DOMContentLoaded:", e); debugLog("Failed to initialize on DOMContentLoaded: " + e.message); document.getElementById('error-message').innerHTML = "Error initializing quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); } }); </script> </body> </html>" frameborder="0" width="100%" height="2000px">
<div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <h2 class="text-xl font-semibold mb-4">Instructions</h2> <h4 class="text-gray-800 text-lg font-semibold mt-6 mb-4">Test Features:</h4> <ul class="space-y-3"> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Multiple choice questions with single correct answers </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Timer-based testing for realistic exam conditions </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Mark questions for review functionality </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Comprehensive results and performance analysis </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Mobile-optimized interface for learning on-the-go </li> </ul> <div class="mt-6 flex space-x-4 button-group md:flex-row flex-col"> <button class="bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="start-test">Start Test</button> </div> <div class="error-message hidden" id="error-message"></div> </div> </section> <!-- Quiz Section --> <section class="container mx-auto px-4 md:px-6 pt-4 md:pt-6 pb-1 hidden section-transition" id="quiz"> <div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <!-- Progress Bar --> <div class="w-full bg-gray-200 rounded-full h-3 mb-4"> <div class="progress-bar h-3 rounded-full" id="progress-bar" style="width: 0%"></div> </div> <!-- Question Header --> <div class="flex flex-col md:flex-row justify-between items-center mb-4"> <h2 class="text-lg font-semibold" id="question-number">Question <span>1</span> of 4</h2> <p class="text-lg font-semibold mt-2 md:mt-0" id="timer">Time Remaining: <span>00:00</span></p> </div> <!-- Question Content --> <div class="mb-6" id="question-content"> <p class="text-gray-800 mb-4" id="question-text"></p> <div class="flex flex-wrap gap-4 mb-4" id="question-images"></div> <div class="space-y-3" id="options"></div> </div> <!-- Navigation Buttons --> <div class="flex flex-col md:flex-row justify-between items-center gap-2 md:gap-4"> <div class="flex gap-2 w-full md:w-auto"> <button class="bg-[#2c5281] text-white px-4 py-3 w-full md:w-32 h-14 rounded-lg hover:bg-[#2c5281] transition" disabled="" id="previous-btn">Previous</button> <button class="bg-[#2c5281] text-white px-4 py-3 w-full md:w-32 h-14 rounded-lg hover:bg-[#2c5281] transition" id="next-btn">Next</button> </div> <div class="flex items-center gap-2"> <button class="bg-transparent text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-100 transition flex items-center gap-1" id="mark-review"> Review <svg xmlns="http://www.w3.org/2000/svg" class="h-5 w-5" viewBox="0 0 20 20" fill="currentColor"> <path d="M10 2a1 1 0 00-1 1v14l3.293-3.293a1 1 0 011.414 0L17 17V3a1 1 0 00-1-1H10z" /> </svg> </button> <button class="bg-transparent text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-100 transition flex items-center gap-1" id="nav-toggle"> Question 🧭 </button> <button class="bg-green-500 text-white px-6 py-3 w-44 h-14 rounded-lg hover:bg-green-600 transition w-full md:w-auto" id="submit-test">Submit Test</button> </div> </div> </section> <!-- Results Section --> <section class="container mx-auto px-4 md:px-6 pt-4 md:pt-6 pb-1 hidden section-transition" id="results"> <div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <h2 class="text-2xl font-semibold mb-4">Anaesthesia Machine - Results</h2> <div class="grid grid-cols-1 md:grid-cols-2 gap-4 mb-6"> <p><strong>Correct:</strong> <span id="correct-count" class="text-[#000000]">0</span></p> <p><strong>Wrong:</strong> <span id="wrong-count" class="text-[#000000]">0</span></p> <p><strong>Unanswered:</strong> <span id="unanswered-count" class="text-[#000000]-500">0</span></p> <p><strong>Marked for Review:</strong> <span id="marked-count" class="text-[#000000]">0</span></p> </div> <h3 class="text-lg font-semibold mb-4" id="result-question-number">Question <span>1</span> of 4</h3> <div class="space-y-6" id="results-content"></div> <div class="result-nav"> <button aria-label="Previous question result" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" disabled="" id="prev-result">Previous</button> <button aria-label="Toggle results navigation panel" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="results-nav-toggle">Result 🧭</button> <button aria-label="Next question result" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="next-result">Next</button> </div> <div class="mt-6 flex space-x-4 button-group md:flex-row flex-col"> <button class="bg-green-500 text-white px-6 py-2 rounded-lg hover:bg-green-600 transition" id="take-again">Take Again</button> </div> </div> </section> <!-- Exit Confirmation Modal --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 hidden" id="exit-modal" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white rounded-lg p-6 max-w-sm w-full"> <h2 class="text-xl font-semibold mb-4">Leave Test?</h2> <p class="text-gray-700 mb-4">Your progress will be lost if you leave this page. Are you sure you want to exit?</p> <div class="flex justify-end space-x-4"> <button class="bg-gray-300 text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-400 transition" id="continue-test">No, Continue</button> <button class="bg-red-500 text-white px-4 py-2 rounded-lg hover:bg-red-600 transition" id="exit-test">Yes, Exit</button> </div> </div> </div> <!-- Submit Confirmation Modal --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 hidden" id="submit-modal" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white rounded-lg p-6 max-w-sm w-full"> <h2 class="text-xl font-semibold mb-4">Confirm Submission</h2> <p class="text-gray-700 mb-2">You have attempted <span id="attempted-count">0</span> of 4 questions.</p> <p class="text-gray-700 mb-4"><span id="unattempted-count">0</span> questions are unattempted.</p> <div class="flex justify-end space-x-4"> <button class="bg-gray-300 text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-400 transition" id="cancel-submit">Cancel</button> <button class="text-white px-4 py-2 rounded-lg hover:bg-[#1a365d] transition" style="background-color: #2c5281;" id="confirm-submit">Submit Test</button> </div> </div> </div> <!-- Quiz Navigation Panel --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 z-50 nav-panel hidden overflow-y-auto" id="nav-panel" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white shadow-lg p-4 rounded-lg w-full max-w-2xl max-h-[80vh] overflow-y-auto"> <h2 class="text-lg font-semibold mb-4">Questions Navigation</h2> <div class="mb-4"> <select class="w-full p-2 border rounded-lg text-gray-700" id="nav-filter"> <option value="all">All Questions</option> <option value="answered">Answered</option> <option value="unanswered">Unanswered</option> <option value="marked">Marked for Review</option> </select> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-nav">Close</button> </div> </div> <!-- Results Navigation Panel --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 z-50 results-nav-panel hidden overflow-y-auto" id="results-nav-panel" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white shadow-lg p-4 rounded-lg w-full max-w-2xl max-h-[80vh] overflow-y-auto"> <h2 class="text-lg font-semibold mb-4">Results Navigation</h2> <div class="mb-4"> <select class="w-full p-2 border rounded-lg text-gray-700" id="results-nav-filter"> <option value="all">All Questions</option> <option value="answered">Answered</option> <option value="unanswered">Unanswered</option> <option value="marked">Marked for Review</option> </select> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="results-nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-results-nav">Close</button> </div> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="results-nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-results-nav">Close</button> </div> <!-- JavaScript Logic --> <script> // Enable debug mode for detailed logging const DEBUG_MODE = true; // Log debug messages function debugLog(message) { if (DEBUG_MODE) { console.log(`[DEBUG] ${message}`); } } // Initialize questions with error handling let questions = []; let currentResultQuestion = 0; // State for current question in results try { debugLog("Attempting to parse questions_json"); questions = [{"text": "A patient with renal laceration has urine extravasation and urinoma formation post conservative management. This kind of laceration that involves the collecting system of kidney is considered what grade of kidney trauma?", "options": [{"label": "A", "text": "Grade 2", "correct": false}, {"label": "B", "text": "Grade 4", "correct": true}, {"label": "C", "text": "Grade 3", "correct": false}, {"label": "D", "text": "Grade 5", "correct": false}], "correct_answer": "B. Grade 4", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Grade 4</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Grade 4 injuries involve peri hilar or branch injuries with urinary extravasation , highlighting the importance of appropriate management strategies such as ureteral stenting or percutaneous nephrostomy to address urinary leaks and prevent complications like urinoma formation.</li><li>➤ Grade 4 injuries involve peri hilar or branch injuries with urinary extravasation</li><li>➤ appropriate management strategies such as ureteral stenting or percutaneous nephrostomy</li><li>➤ address urinary leaks</li><li>➤ Management - persistent urinoma requires ureteral scenting .</li><li>➤ Management</li><li>➤ persistent urinoma requires ureteral scenting</li><li>➤ If not cured by this, percutaneous nephrostomy or transcutaneous drain may be required.</li><li>➤ Ref : Sabiston Textbook of Surgery 20th Edition Page 2091</li><li>➤ Ref : Sabiston Textbook of Surgery 20th Edition Page 2091</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Subarachnoid haemorrhage is most commonly seen due to:", "options": [{"label": "A", "text": "Berry aneurysm rupture", "correct": false}, {"label": "B", "text": "Trauma", "correct": true}, {"label": "C", "text": "Arteriosclerosis", "correct": false}, {"label": "D", "text": "Diabetic vasculopathy", "correct": false}], "correct_answer": "B. Trauma", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/picture12_Ut6g69B.jpg"], "explanation": "<p><strong>Ans. B) Trauma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Berry Aneurysm Rupture Rupture of a berry aneurysm, or saccular aneurysm , is the most common cause of spontaneous subarachnoid hemorrhage. These aneurysms are often located at the bifurcations of the Circle of Willis in the brain . When they rupture, they cause bleeding into the subarachnoid space, often presenting with a sudden, severe headache (often described as \"the worst headache of my life\"), and may be associated with significant vasospasm leading to further complications.</li><li>• Option A: Berry Aneurysm Rupture</li><li>• saccular aneurysm</li><li>• common cause of spontaneous subarachnoid hemorrhage.</li><li>• aneurysms</li><li>• located at the bifurcations of the Circle of Willis in the brain</li><li>• Option C: Arteriosclerosis Arteriosclerosis can lead to several types of stroke, including intracerebral hemorrhage, due to weakening of the vessel walls . However, it is not a common cause of subarachnoid hemorrhage compared to trauma or aneurysm rupture.</li><li>• Option C: Arteriosclerosis</li><li>• lead to several types of stroke, including intracerebral hemorrhage,</li><li>• weakening of the vessel walls</li><li>• Option D: Diabetic Vasculopathy Diabetic vasculopathy can contribute to a variety of vascular complications , particularly microvascular and macrovascular diseases . While it increases the risk of stroke, it is not commonly associated with subarachnoid hemorrhage.</li><li>• Option D: Diabetic Vasculopathy</li><li>• contribute to a variety of vascular complications</li><li>• microvascular and macrovascular diseases</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ While berry aneurysm rupture is the most common cause of spontaneous SAH , trauma is the most common cause of SAH overall . Understanding the different clinical presentations and complications, such as vasospasm in aneurysmal SAH, is crucial for appropriate diagnosis and management.</li><li>➤ berry aneurysm rupture is the most common cause of spontaneous SAH</li><li>➤ trauma</li><li>➤ most common cause of SAH overall</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 367</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 367</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In a case of blast injury, which of the following organs is least susceptible to injury due to the blast wave itself?", "options": [{"label": "A", "text": "GI tract", "correct": false}, {"label": "B", "text": "Liver", "correct": true}, {"label": "C", "text": "Lungs", "correct": false}, {"label": "D", "text": "Middle ear", "correct": false}], "correct_answer": "B. Liver", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: GI tract The gastrointestinal (GI) tract is particularly vulnerable to primary blast injuries due to the presence of gas within the intestines , which makes them susceptible to the blast wave.</li><li>• Option A: GI tract</li><li>• vulnerable to primary blast injuries due to the presence of gas within the intestines</li><li>• Option C: Lungs The lungs are very susceptible to blast injuries because of their air-filled nature and delicate structure. They are often the site of primary blast injuries.</li><li>• Option C: Lungs</li><li>• susceptible to blast injuries</li><li>• air-filled nature and delicate structure.</li><li>• Option D: Middle ear The middle ear contains air and is particularly sensitive to pressure changes , making it highly susceptible to blast wave injuries , often resulting in tympanic membrane rupture .</li><li>• Option D: Middle ear</li><li>• contains air and is particularly sensitive to pressure changes</li><li>• highly susceptible to blast wave injuries</li><li>• tympanic membrane rupture</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ To understand the susceptibility of different organs to primary blast injury . Primary blast injuries most commonly affect air-filled organs like the gastrointestinal tract, lungs, and middle ear due to the rapid pressure changes associated with the blast wave . Solid organs like the liver are less susceptible to the primary blast wave but can be affected by secondary and tertiary mechanisms of injury.</li><li>➤ susceptibility of different organs to primary blast injury</li><li>➤ affect air-filled organs like the gastrointestinal tract, lungs, and middle ear due to the rapid pressure changes associated with the blast wave</li><li>➤ The most common organ injured in blast (primary): Tympanic membrane &gt; Lungs &gt; GIT The most common operative finding of intestinal blast is sub-serosal haemorrhage</li><li>➤ The most common organ injured in blast (primary): Tympanic membrane &gt; Lungs &gt; GIT</li><li>➤ The most common operative finding of intestinal blast is sub-serosal haemorrhage</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition- Pages 466-469</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition- Pages 466-469</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A factory worker fell from a crane and sustained multiple injuries, including an open fracture of the right tibial shaft. The emergency team reached the site of the accident. What is the ideal number of people required to log roll this patient of trauma?", "options": [{"label": "A", "text": "3", "correct": false}, {"label": "B", "text": "5", "correct": true}, {"label": "C", "text": "4", "correct": false}, {"label": "D", "text": "2", "correct": false}], "correct_answer": "B. 5", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/picture3_SeRHQz5.jpg"], "explanation": "<p><strong>Ans. B) 5</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• The 10th Edition of ATLS recommends a minimum of 4 people for log rolling a patient of trauma , while ideal number of people is 5 .</li><li>• 10th Edition of ATLS</li><li>• minimum of 4 people for log rolling a patient of trauma</li><li>• ideal number of people is 5</li><li>• **In patients with a fracture of an extremity would require a minimum of 5 people.</li><li>• Log rolling of a patient of trauma :</li><li>• Log rolling of a patient of trauma</li><li>• 1st person - restricts motion of head and neck .</li><li>• 1st person</li><li>• restricts motion of head and neck</li><li>• 2nd person - positioned on the same side as the patient's torso , prevents flexion, extension, segmental rotation, lateral bending or sagging of chest or abdomen while transferring the patient.</li><li>• 2nd person</li><li>• same side as the patient's torso</li><li>• prevents flexion, extension, segmental rotation, lateral bending</li><li>• 3rd person - moves patient's legs.</li><li>• 3rd person</li><li>• patient's legs.</li><li>• 4th person - removes backboard and examines the back.</li><li>• 4th person</li><li>• removes backboard</li><li>• Fig: Four-Person Logroll. At least four people are needed for logrolling a patient to remove a spine board and/or examine the back. A. One person stands at the patient’s head to control the head and c-spine, and two are along the patient’s sides to control the body and extremities. B. As the patient is rolled, three people maintain alignment of the spine while C. the fourth person removes the board and examines the back. D. Once the board is removed, three people return the patient to the supine while maintaining alignment of the spine.</li><li>• Fig:</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ To recognize the appropriate number of people required to safely perform a log roll on a trauma patient . According to ATLS guidelines , a minimum of four people is recommended for log rolling a patient, while five people are ideal when the patient has an extremity fracture to adequately support the head, neck, torso, limbs , and facilitate examination of the back.</li><li>➤ appropriate number of people required to safely perform a log roll on a trauma patient</li><li>➤ ATLS guidelines</li><li>➤ minimum of four people is recommended for log rolling</li><li>➤ five people are ideal when the patient has an extremity fracture</li><li>➤ support the head, neck, torso, limbs</li><li>➤ Ref : ATLS Student Course Manual 10th Edition- Page 143.</li><li>➤ Ref</li><li>➤ : ATLS Student Course Manual 10th Edition- Page 143.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Read the following statements about adjuncts to primary survey in a case of trauma and categorise them as true (T) or false (F): Arterial blood gas is a useful indicator of shock in patients of trauma and trending these values can reflect improvements with resuscitation. In patients with suspected fracture of cribriform plate, gastric tube has to inserted nasally. It is essential to catheterize the patient trans-urethrally before you can proceed to examine the perineum and genitalia.", "options": [{"label": "A", "text": "T T F", "correct": false}, {"label": "B", "text": "F T F", "correct": false}, {"label": "C", "text": "T F F", "correct": true}, {"label": "D", "text": "F T T", "correct": false}], "correct_answer": "C. T F F", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) T F F</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Arterial blood gas (ABG) is indeed a useful indicator of shock in trauma patients and can reflect changes in response to resuscitation efforts . If a cribriform plate fracture is suspected , inserting a gastric tube nasally is contraindicated due to the risk of entering the cranial vault . Catheterization should not be done trans-urethrally before examining the perineum and genitalia , particularly if there is evidence of potential urethral injury.</li><li>• Arterial blood gas (ABG) is indeed a useful indicator of shock in trauma patients and can reflect changes in response to resuscitation efforts .</li><li>• Arterial blood gas</li><li>• useful indicator of shock in trauma patients</li><li>• reflect changes</li><li>• response to resuscitation efforts</li><li>• If a cribriform plate fracture is suspected , inserting a gastric tube nasally is contraindicated due to the risk of entering the cranial vault .</li><li>• cribriform plate fracture is suspected</li><li>• gastric tube nasally</li><li>• risk of entering the cranial vault</li><li>• Catheterization should not be done trans-urethrally before examining the perineum and genitalia , particularly if there is evidence of potential urethral injury.</li><li>• Catheterization</li><li>• not be done trans-urethrally</li><li>• examining the perineum and genitalia</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ To understand the appropriate use of adjuncts during the primary survey in trauma care . Arterial blood gases are valuable for assessing shock and response to resuscitation. Gastric tubes should be inserted orally in the context of potential cribriform plate fractures to avoid intracranial passage . Lastly, a careful examination of the perineum and genitalia is necessary before catheterization to avoid exacerbating any potential urethral injuries.</li><li>➤ appropriate use of adjuncts during the primary survey in trauma care</li><li>➤ Arterial blood gases</li><li>➤ valuable for assessing shock</li><li>➤ response to resuscitation.</li><li>➤ Gastric tubes</li><li>➤ inserted orally in the context of potential cribriform plate fractures</li><li>➤ avoid intracranial passage</li><li>➤ Ref : ATLS Student Course Manual 10th Edition- Page 11</li><li>➤ Ref : ATLS Student Course Manual 10th Edition- Page 11</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is not a component of managing severe hypovolemia in trauma (Damage Control Resuscitation)?", "options": [{"label": "A", "text": "Limited use of warmed crystalloids", "correct": false}, {"label": "B", "text": "Massive transfusion protocol using PRBC: FFP: Platelets in 1:1:1", "correct": false}, {"label": "C", "text": "Maintaining Systolic BP between 70-90 mm of Hg in head trauma", "correct": true}, {"label": "D", "text": "Early damage control surgery for haemorrhage control", "correct": false}], "correct_answer": "C. Maintaining Systolic BP between 70-90 mm of Hg in head trauma", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Maintaining Systolic BP between 70-90 mm of Hg in head trauma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Limited use of warmed crystalloids DCR emphasizes the limited use of crystalloids to avoid complications such as dilutional coagulopathy, hypothermia, and abdominal compartment syndrome .</li><li>• Option A: Limited use of warmed crystalloids</li><li>• use of crystalloids to avoid complications</li><li>• dilutional coagulopathy, hypothermia, and abdominal compartment syndrome</li><li>• Option B: Massive transfusion protocol using PRBC: FFP: Platelets in 1:1:1 A massive transfusion protocol is often a component of DCR , focusing on the early administration of blood products to manage hemorrhagic shock and maintain hemostasis . The 1:1:1 ratio aims to approximate whole blood and address coagulopathy.</li><li>• Option B: Massive transfusion protocol using PRBC: FFP: Platelets in 1:1:1</li><li>• massive transfusion protocol</li><li>• component of DCR</li><li>• focusing on the early administration of blood products</li><li>• manage hemorrhagic shock</li><li>• hemostasis</li><li>• Option D: Early damage control surgery for hemorrhage control Damage control surgery is an integral part of DCR , aiming to quickly control bleeding and contamination in the acute phase , which is then followed by definitive surgery after the patient's physiology has been stabilized.</li><li>• Option D: Early damage control surgery for hemorrhage control</li><li>• integral part of DCR</li><li>• control bleeding and contamination in the acute phase</li><li>• definitive surgery after the patient's physiology has been stabilized.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ To understand the components of Damage Control Resuscitation in the management of severe hypovolemia in trauma patients . DCR includes the limited use of warmed crystalloids , the implementation of a massive transfusion protocol with a balanced ratio of PRBCs, FFP, and platelets , and early surgical intervention to control hemorrhage . Maintaining a lower systolic blood pressure may be part of permissive hypotension in trauma without head injury, but in cases of head trauma, a higher systolic blood pressure (&gt;90 mmHg) is recommended to ensure adequate cerebral perfusion and oxygenation.</li><li>➤ Damage Control Resuscitation</li><li>➤ management of severe hypovolemia in trauma patients</li><li>➤ DCR</li><li>➤ limited use of warmed crystalloids</li><li>➤ implementation of a massive transfusion protocol</li><li>➤ balanced ratio of PRBCs, FFP, and platelets</li><li>➤ early surgical intervention to control hemorrhage</li><li>➤ Ref : Bailey 28 th Ed. Pg 355.</li><li>➤ Ref</li><li>➤ Bailey 28 th Ed. Pg 355.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the incorrect statement about cervical spine injury:", "options": [{"label": "A", "text": "The absence of neurological impairment on clinical examination alone excludes injury to cervical spine", "correct": true}, {"label": "B", "text": "A patient of trauma wearing a helmet and requiring airway management requires a 2-person procedure for helmet removal", "correct": false}, {"label": "C", "text": "Imaging for cervical spine may be excluded in a patient meeting all requirements of NEXUS criteria", "correct": false}, {"label": "D", "text": "If a spinal fracture is identified, further imaging of the whole spine is required", "correct": false}], "correct_answer": "A. The absence of neurological impairment on clinical examination alone excludes injury to cervical spine", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) The absence of neurological impairment based on clinical examination alone excludes</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Correct When a trauma patient wearing a helmet requires airway management, helmet removal should be a two-person procedure to minimize the risk of exacerbating a potential cervical spine injury. One person stabilizes the neck, while the other removes the helmet carefully.</li><li>• Option B: Correct</li><li>• Option C: Correct The NEXUS criteria are used to determine whether cervical spine imaging is necessary . If a patient meets all the NEXUS criteria, imaging may not be required, which helps to avoid unnecessary radiation exposure.</li><li>• Option C: Correct</li><li>• NEXUS criteria</li><li>• determine whether cervical spine imaging is necessary</li><li>• Option D: Correct If a spinal fracture is identified , further imaging of the whole spine is often required because of the possibility of non-contiguous spinal injuries , which occur in a significant minority of cases.</li><li>• Option D: Correct</li><li>• spinal fracture is identified</li><li>• imaging of the whole spine is often required</li><li>• possibility of non-contiguous spinal injuries</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Clinical examination alone is insufficient to exclude cervical spine injuries in trauma patients . Imaging studies are crucial when clinical assessment raises suspicion, even in the absence of neurological impairment. The NEXUS criteria guide when imaging may be safely omitted , and the identification of one spinal injury necessitates a thorough search for additional injuries.</li><li>➤ insufficient to exclude cervical spine injuries in trauma patients</li><li>➤ NEXUS criteria guide when imaging may be safely omitted</li><li>➤ identification of one spinal injury necessitates a thorough search for additional injuries.</li><li>➤ NEXUS criteria: Cervical spine radiograph should be obtained with any 1 of the following:</li><li>➤ NEXUS criteria:</li><li>➤ Neurological deficits</li><li>➤ Ethanol intoxication</li><li>➤ extreme distracting injury</li><li>➤ altered consciousness/unconscious (unable to provide history)</li><li>➤ spinal tenderness.</li><li>➤ Ref : ATLS Student Course Manual 10th Edition- Pages 16, 27, 140</li><li>➤ Ref : ATLS Student Course Manual 10th Edition- Pages 16, 27, 140</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition- Page 392</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition- Page 392</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient who was stabbed in the chest was rushed into the ER with a 4 cm large sucking wound to the left side of his chest. His SpO2 was 88%. On examination, the left side of chest showed decreased movements and breath sounds were absent on that side, on auscultation. Regarding the above condition, pick the correct statements: It is a case of open pneumothorax. Air gets preferentially drawn through the wound instead of the trachea, on inspiration. It requires no immediate management. Wait and watch policy is used. Immediately apply a 3-way occlusive dressing over the wound. Later, a chest tube need not be inserted.", "options": [{"label": "A", "text": "1, 3, 5", "correct": false}, {"label": "B", "text": "1, 2, 3", "correct": false}, {"label": "C", "text": "1, 2, 4", "correct": true}, {"label": "D", "text": "1, 4, 5", "correct": false}], "correct_answer": "C. 1, 2, 4", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture12.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture13.jpg"], "explanation": "<p><strong>Ans. C) 1,2,4</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• This is a case of open pneumothorax / sucking chest wound.</li><li>• It is a case of open pneumothorax : This is correct . An open pneumothorax, also known as a \"sucking chest wound,\" occurs when there is an opening in the chest wall large enough for air to pass in and out during respiration, causing the lung on the affected side to collapse. Air gets preferentially drawn through the wound instead of the trachea, on inspiration : This statement is also correct . In the case of an open pneumothorax, during inspiration, air may enter the chest cavity through the wound because it follows the path of least resistance, if wound is &gt; 3 cm in width. This can prevent the lung from expanding properly. It requires no immediate management. Wait and watch policy is used : This statement is incorrect . An open pneumothorax is a life-threatening condition and requires immediate management to prevent further lung collapse and to re-expand the affected lung. Immediately apply a 3-way occlusive dressing over the wound : This statement is partially correct . Immediate management typically involves applying an occlusive dressing that is taped on three sides , which acts as a valve to let air out but not in . This can help prevent a tension pneumothorax, where air accumulates under pressure and can compress the heart and other vital structures. Later, a chest tube need not be inserted : This statement is incorrect . The standard treatment for an open pneumothorax usually involves inserting a chest tube to re-expand the lung and evacuate air from the pleural space .</li><li>• It is a case of open pneumothorax : This is correct . An open pneumothorax, also known as a \"sucking chest wound,\" occurs when there is an opening in the chest wall large enough for air to pass in and out during respiration, causing the lung on the affected side to collapse.</li><li>• It is a case of open pneumothorax</li><li>• correct</li><li>• Air gets preferentially drawn through the wound instead of the trachea, on inspiration : This statement is also correct . In the case of an open pneumothorax, during inspiration, air may enter the chest cavity through the wound because it follows the path of least resistance, if wound is &gt; 3 cm in width. This can prevent the lung from expanding properly.</li><li>• Air gets preferentially drawn through the wound instead of the trachea, on inspiration</li><li>• correct</li><li>• It requires no immediate management. Wait and watch policy is used : This statement is incorrect . An open pneumothorax is a life-threatening condition and requires immediate management to prevent further lung collapse and to re-expand the affected lung.</li><li>• It requires no immediate management. Wait and watch policy is used</li><li>• incorrect</li><li>• open pneumothorax is a life-threatening condition</li><li>• requires immediate management</li><li>• Immediately apply a 3-way occlusive dressing over the wound : This statement is partially correct . Immediate management typically involves applying an occlusive dressing that is taped on three sides , which acts as a valve to let air out but not in . This can help prevent a tension pneumothorax, where air accumulates under pressure and can compress the heart and other vital structures.</li><li>• Immediately apply a 3-way occlusive dressing over the wound</li><li>• partially correct</li><li>• Immediate management</li><li>• applying an occlusive dressing that is taped on three sides</li><li>• valve to let air out but not in</li><li>• Later, a chest tube need not be inserted : This statement is incorrect . The standard treatment for an open pneumothorax usually involves inserting a chest tube to re-expand the lung and evacuate air from the pleural space .</li><li>• Later, a chest tube need not be inserted</li><li>• incorrect</li><li>• open pneumothorax</li><li>• inserting a chest tube to re-expand the lung</li><li>• evacuate air from the pleural space</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Understand the management of open pneumothorax , recognizing the need for immediate intervention with a three-sided occlusive dressing followed by chest tube insertion .</li><li>➤ management of open pneumothorax</li><li>➤ need for immediate intervention with a three-sided occlusive dressing</li><li>➤ chest tube insertion</li><li>➤ Large injuries to the chest wall (&gt;3 cm) that remain open can result in an open pneumothorax, also known as a sucking chest, wound . Equilibration between intrathoracic pressure and atmospheric pressure is immediate. Because air tends to follow the path of least resistance, when the opening in the chest wall is approximately two-thirds the diameter of the trachea or greater, air passes preferentially through the chest wall defect with each inspiration. Effective ventilation is thereby impaired, leading to hypoxia and hypercarbia. The clinical signs and symptoms are pain, difficulty breathing, tachypnea, decreased breath sounds on the affected side, and noisy movement of air through the chest wall injury.</li><li>➤ Large injuries to the chest wall (&gt;3 cm) that remain open can result in an open pneumothorax, also known as a sucking chest, wound . Equilibration between intrathoracic pressure and atmospheric pressure is immediate. Because air tends to follow the path of least resistance, when the opening in the chest wall is approximately two-thirds the diameter of the trachea or greater, air passes preferentially through the chest wall defect with each inspiration. Effective ventilation is thereby impaired, leading to hypoxia and hypercarbia.</li><li>➤ Large injuries to the chest wall</li><li>➤ remain open can result in an open pneumothorax,</li><li>➤ sucking chest, wound</li><li>➤ The clinical signs and symptoms are pain, difficulty breathing, tachypnea, decreased breath sounds on the affected side, and noisy movement of air through the chest wall injury.</li><li>➤ Fig: Open Pneumothorax. Large defects of the chest wall that remain open can result in an open pneumothorax, or sucking chest wound.</li><li>➤ Fig:</li><li>➤ For initial management of an open pneumothorax, promptly close the defect with a sterile dressing large enough to overlap the wound’s edges. Any occlusive dressing (e.g. plastic wrap or petrolatum gauze) may be used as a temporary measure to enable rapid assessment to continue. Tape it securely on only three sides to provide a flutter-valve effect. As the patient breathes in, the dressing occludes the wound, preventing air from entering. During exhalation, the open end of the dressing allows air to escape from the pleural space. Taping all 4 edges of the dressing can cause air to accumulate in the thoracic cavity, resulting in a tension pneumothorax unless a chest tube is in place. Place a chest tube remote from the wound as soon as possible. Subsequent definitive surgical closure of the wound is frequently required.</li><li>➤ For initial management of an open pneumothorax, promptly close the defect with a sterile dressing large enough to overlap the wound’s edges. Any occlusive dressing (e.g. plastic wrap or petrolatum gauze) may be used as a temporary measure to enable rapid assessment to continue. Tape it securely on only three sides to provide a flutter-valve effect.</li><li>➤ initial management of an open pneumothorax,</li><li>➤ close the defect with a sterile dressing large enough to overlap the wound’s edges.</li><li>➤ As the patient breathes in, the dressing occludes the wound, preventing air from entering. During exhalation, the open end of the dressing allows air to escape from the pleural space. Taping all 4 edges of the dressing can cause air to accumulate in the thoracic cavity, resulting in a tension pneumothorax unless a chest tube is in place. Place a chest tube remote from the wound as soon as possible. Subsequent definitive surgical closure of the wound is frequently required.</li><li>➤ Fig: Dressing for Treatment of Open Pneumothorax. Promptly close the defect with a sterile occlusive dressing that is large enough to overlap the wound’s edges. Tape it securely on three sides to provide a flutter-valve effect.</li><li>➤ Fig:</li><li>➤ Ref : ATLS Student Manual 10th Edition Page 67</li><li>➤ Ref</li><li>➤ : ATLS Student Manual 10th Edition Page 67</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 374</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 374</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "The following patients are victims of a mass casualty. Assign appropriate triage codes to them:", "options": [{"label": "A", "text": "1-D, 2-B, 3-C, 4-A", "correct": false}, {"label": "B", "text": "1-C, 2-A, 3-D, 4-B", "correct": true}, {"label": "C", "text": "1-B, 2-C, 3-D, 4-A", "correct": false}, {"label": "D", "text": "1-C, 2-D, 3-A, 4-B", "correct": false}], "correct_answer": "B. 1-C, 2-A, 3-D, 4-B", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/screenshot-2024-03-19-155640.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/screenshot-2024-03-19-155951.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/picture1_T1dVqkv.jpg"], "explanation": "<p><strong>Ans. B) 1-C, 2-A, 3-D, 4-B</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• In mass casualty incidents , triage is used to prioritize patients based on the severity of their injuries and their potential for survival with immediate treatment . A four-tier system is commonly used :</li><li>• mass casualty incidents</li><li>• triage is used to prioritize patients</li><li>• severity of their injuries</li><li>• their potential for survival</li><li>• immediate treatment</li><li>• four-tier system is commonly used</li><li>• Red : Immediate care needed ; life-threatening injuries with a good chance of survival if treated promptly. Yellow : Delayed care ; serious injuries but not immediately life-threatening and the patient can wait for a short period without loss of life or limb. Green : Minor injuries ; the patient can wait for longer periods for care without significant risk. Black : Expectant; injuries are so severe that survival is unlikely even with treatment.</li><li>• Red : Immediate care needed ; life-threatening injuries with a good chance of survival if treated promptly.</li><li>• Red</li><li>• Immediate care needed</li><li>• Yellow : Delayed care ; serious injuries but not immediately life-threatening and the patient can wait for a short period without loss of life or limb.</li><li>• Yellow</li><li>• Delayed care</li><li>• Green : Minor injuries ; the patient can wait for longer periods for care without significant risk.</li><li>• Green</li><li>• Minor injuries</li><li>• Black : Expectant; injuries are so severe that survival is unlikely even with treatment.</li><li>• Black</li><li>• Expectant;</li><li>• A patient with hemothorax (1) needs immediate care , so red is appropriate.</li><li>• hemothorax</li><li>• needs immediate care</li><li>• A compound tibial fracture (2) can wait without significant risk of loss of life , so yellow is suitable.</li><li>• tibial fracture</li><li>• can wait without significant risk of loss of life</li><li>• A laceration on the arm (3) is minor, hence green.</li><li>• arm</li><li>• is minor, hence green.</li><li>• A patient with 90% burns (4) is moribund and would be categorized as black .</li><li>• 90% burns</li><li>• moribund and would be categorized as black</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The educational objective is to assign appropriate triage codes in a mass casualty incident . A patient with hemothorax requires immediate intervention (red), a compound tibial fracture requires delayed care (yellow), a laceration on the arm is a minor injury (green), and a patient with 90% fourth-degree burns is expectant (black).</li><li>➤ assign appropriate triage codes in a mass casualty incident</li><li>➤ hemothorax</li><li>➤ immediate intervention</li><li>➤ compound tibial fracture</li><li>➤ delayed care</li><li>➤ laceration on the arm is a minor injury</li><li>➤ 90% fourth-degree burns is expectant</li><li>➤ Ref : Bailey &amp; Love’s Short Practice of Surgery - 28th Edition Page 449</li><li>➤ Ref</li><li>➤ : Bailey &amp; Love’s Short Practice of Surgery - 28th Edition Page 449</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the components of Revised Trauma Score? Pulse rate Respiratory rate Patient age Glasgow coma scale Systolic BP", "options": [{"label": "A", "text": "a, b, d", "correct": false}, {"label": "B", "text": "a, d, e", "correct": false}, {"label": "C", "text": "b, d, e", "correct": true}, {"label": "D", "text": "b, c, e", "correct": false}], "correct_answer": "C. b, d, e", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/screenshot-2024-03-19-160101.jpg"], "explanation": "<p><strong>Ans. C) b, d, e</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• The Revised Trauma Score (RTS) is a physiological scoring system , with the intent to provide an assessment of the severity of a trauma patient's condition . The components of the RTS include:</li><li>• Revised Trauma Score</li><li>• physiological scoring system</li><li>• intent to provide an assessment</li><li>• severity of a trauma patient's condition</li><li>• b. Respiratory rate d. Glasgow Coma Scale e. Systolic BP</li><li>• b. Respiratory rate</li><li>• d. Glasgow Coma Scale</li><li>• e. Systolic BP</li><li>• These three parameters are used to calculate the RTS , which can help to predict the patient's chances of survival . Each component is given a score , and the sum of these scores is used to determine the overall RTS .</li><li>• three parameters</li><li>• calculate the RTS</li><li>• help to predict the patient's chances of survival</li><li>• component is given a score</li><li>• sum of these scores is used to determine the overall RTS</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Understand the components of the Revised Trauma Score (RTS) as a tool for assessing the severity of trauma , which includes the patient's respiratory rate , Glasgow Coma Scale score , and systolic blood pressure . Lower RTS scores correlate with higher injury severity and potentially lower chances of survival .</li><li>➤ components of the Revised Trauma Score</li><li>➤ tool for assessing the severity of trauma</li><li>➤ patient's respiratory rate</li><li>➤ Glasgow Coma Scale score</li><li>➤ systolic blood pressure</li><li>➤ Lower RTS scores</li><li>➤ higher injury severity</li><li>➤ potentially lower chances of survival</li><li>➤ Other trauma scoring systems include:</li><li>➤ Abbreviated Injury Scale (AIS) : Codes injuries on a scale from 1 (minimally severe) to 6 (presumably fatal). Injury Severity Score (ISS) : Ranges from 3-75 , and is the summation of the squares of the highest AIS severity codes for the three most severely injured body regions. Mangled Extremity Severity Score (MESS) : Includes factors like the energy causing injury , limb ischemia , shock , and patient age. TRISS (Trauma and Injury Severity Score) : Combines the ISS, RTS, the mechanism of injury, and the patient's age to estimate survival.</li><li>➤ Abbreviated Injury Scale (AIS) : Codes injuries on a scale from 1 (minimally severe) to 6 (presumably fatal).</li><li>➤ Abbreviated Injury Scale (AIS)</li><li>➤ Codes injuries</li><li>➤ scale from 1</li><li>➤ to 6</li><li>➤ Injury Severity Score (ISS) : Ranges from 3-75 , and is the summation of the squares of the highest AIS severity codes for the three most severely injured body regions.</li><li>➤ Injury Severity Score (ISS)</li><li>➤ 3-75</li><li>➤ summation of the squares</li><li>➤ highest AIS severity codes</li><li>➤ Mangled Extremity Severity Score (MESS) : Includes factors like the energy causing injury , limb ischemia , shock , and patient age.</li><li>➤ Mangled Extremity Severity Score (MESS)</li><li>➤ energy causing injury</li><li>➤ limb ischemia</li><li>➤ shock</li><li>➤ TRISS (Trauma and Injury Severity Score) : Combines the ISS, RTS, the mechanism of injury, and the patient's age to estimate survival.</li><li>➤ TRISS (Trauma and Injury Severity Score)</li><li>➤ ISS, RTS, the mechanism of injury,</li><li>➤ patient's age to estimate survival.</li><li>➤ Ref: Sabiston Textbook of Surgery 21 st Edition Page 389</li><li>➤ Ref: Sabiston Textbook of Surgery 21 st Edition Page 389</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the correct statements? Tranexamic acid reduces risk of mortality only in patients of penetrating trauma with no role in blunt trauma cases All patients with signs of shock should receive tranexamic acid within 3 hours of injury Crystalloids are preferred over blood and blood products for resuscitation of severely hypovolemic patients of trauma The first step in primary survey in field trauma patient is control of any exsanguinating haemorrhage", "options": [{"label": "A", "text": "1,2", "correct": false}, {"label": "B", "text": "2,3", "correct": false}, {"label": "C", "text": "2,4", "correct": true}, {"label": "D", "text": "1,4", "correct": false}], "correct_answer": "C. 2,4", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) 2,4</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Based on the given statements, let's identify the correct ones regarding the management of trauma patients:</li><li>• Tranexamic acid reduces risk of mortality only in patients of penetrating trauma with no role in blunt trauma cases This statement is incorrect . Tranexamic acid has been shown to reduce the risk of mortality from bleeding in both penetrating and blunt trauma cases , as evidenced by the CRASH-2 trial. All patients with signs of shock should receive tranexamic acid within 3 hours of injury This statement is correct . The CRASH-2 trial also indicated that tranexamic acid is beneficial when administered within 3 hours of injury to patients with signs of significant hemorrhage or shock. Crystalloids are preferred over blood and blood products for resuscitation of severely hypovolemic patients of trauma This statement is incorrect. In severely hypovolemic trauma patients, blood and blood products are preferred to restore circulating volume and oxygen-carrying capacity. Crystalloids can be used temporarily while awaiting blood products but are not the resuscitation fluid of choice in severe hemorrhage . The first step in primary survey in field trauma patient is control of any exsanguinating haemorrhage This statement is correct . In trauma care, particularly in the pre-hospital setting, the first step in the primary survey is to control any life-threatening external hemorrhage before proceeding with airway, breathing, and circulation (ABCs) assessment and management.</li><li>• Tranexamic acid reduces risk of mortality only in patients of penetrating trauma with no role in blunt trauma cases This statement is incorrect . Tranexamic acid has been shown to reduce the risk of mortality from bleeding in both penetrating and blunt trauma cases , as evidenced by the CRASH-2 trial.</li><li>• Tranexamic acid reduces risk of mortality only in patients of penetrating trauma with no role in blunt trauma cases</li><li>• incorrect</li><li>• reduce the risk of mortality from bleeding</li><li>• both penetrating and blunt trauma cases</li><li>• All patients with signs of shock should receive tranexamic acid within 3 hours of injury This statement is correct . The CRASH-2 trial also indicated that tranexamic acid is beneficial when administered within 3 hours of injury to patients with signs of significant hemorrhage or shock.</li><li>• All patients with signs of shock should receive tranexamic acid within 3 hours of injury</li><li>• correct</li><li>• Crystalloids are preferred over blood and blood products for resuscitation of severely hypovolemic patients of trauma This statement is incorrect. In severely hypovolemic trauma patients, blood and blood products are preferred to restore circulating volume and oxygen-carrying capacity. Crystalloids can be used temporarily while awaiting blood products but are not the resuscitation fluid of choice in severe hemorrhage .</li><li>• Crystalloids are preferred over blood and blood products for resuscitation of severely hypovolemic patients of trauma</li><li>• incorrect.</li><li>• Crystalloids</li><li>• used temporarily while awaiting blood products but are not the resuscitation fluid of choice in severe hemorrhage</li><li>• The first step in primary survey in field trauma patient is control of any exsanguinating haemorrhage This statement is correct . In trauma care, particularly in the pre-hospital setting, the first step in the primary survey is to control any life-threatening external hemorrhage before proceeding with airway, breathing, and circulation (ABCs) assessment and management.</li><li>• The first step in primary survey in field trauma patient is control of any exsanguinating haemorrhage</li><li>• correct</li><li>• The correct options, therefore, are 2 and 4 .</li><li>• 2 and 4</li><li>• The answer is C. 2,4 .</li><li>• C. 2,4</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The key points in trauma management include administering tranexamic acid within 3 hours to patients with signs of significant hemorrhage , using blood and blood products for the resuscitation of severely hypovolemic patients , and controlling life-threatening hemorrhage as a first step in the primary survey of trauma patients.</li><li>➤ trauma management</li><li>➤ administering tranexamic acid within 3 hours to patients</li><li>➤ signs of significant hemorrhage</li><li>➤ blood and blood products for the resuscitation of severely hypovolemic patients</li><li>➤ Tranexamic acid is an antifibrinolytic drug that reduces the risk of mortality from bleeding in both blunt and penetrating trauma . This was shown by the CRASH 2 trial. It should be given to all trauma patients suspected to have significant haemorrhage, including those with SBP of &lt;110 mm Hg or a pulse of over 110/min. It must be administered within 3 hours of injury. The dose given is 1g dose over 10 mins followed by 1g dose over 8 hrs . Severely hypovolemic trauma patients should be resuscitated using blood and blood products. The only role for crystalloids in the initial management of such patients is for administration of small quantities to maintain BP while waiting for blood products to arrive.</li><li>➤ Tranexamic acid is an antifibrinolytic drug that reduces the risk of mortality from bleeding in both blunt and penetrating trauma . This was shown by the CRASH 2 trial. It should be given to all trauma patients suspected to have significant haemorrhage, including those with SBP of &lt;110 mm Hg or a pulse of over 110/min. It must be administered within 3 hours of injury.</li><li>➤ Tranexamic acid</li><li>➤ antifibrinolytic drug that reduces the risk of mortality from bleeding in both blunt and penetrating trauma</li><li>➤ The dose given is 1g dose over 10 mins followed by 1g dose over 8 hrs .</li><li>➤ dose given is 1g dose over 10 mins</li><li>➤ 1g dose over 8 hrs</li><li>➤ Severely hypovolemic trauma patients should be resuscitated using blood and blood products. The only role for crystalloids in the initial management of such patients is for administration of small quantities to maintain BP while waiting for blood products to arrive.</li><li>➤ Ref : Bailey &amp; Love’s Short Practice of Surgery- 28th Edition Page 356</li><li>➤ Ref : Bailey &amp; Love’s Short Practice of Surgery- 28th Edition Page 356</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Pick the incorrect statement regarding the utility of eFAST in trauma patients:", "options": [{"label": "A", "text": "Non-invasive and can be performed at the same time as resuscitation", "correct": false}, {"label": "B", "text": "Reliably excludes injury in penetrating trauma", "correct": true}, {"label": "C", "text": "Cannot reliably detect 80 ml of free blood", "correct": false}, {"label": "D", "text": "Unreliable for assessment of retroperitoneum", "correct": false}], "correct_answer": "B. Reliably excludes injury in penetrating trauma", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Reliably excludes injury in penetrating trauma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• In the context of trauma care, the extended Focused Assessment with Sonography for Trauma (eFAST) is a valuable diagnostic tool with certain limitations. Here's an assessment of the given statements:</li><li>• Option A: Non-invasive and can be performed at the same time as resuscitation This statement is correct . eFAST is non-invasive, can be quickly performed at the bedside, and does not interfere with resuscitative efforts.</li><li>• Option A: Non-invasive and can be performed at the same time as resuscitation</li><li>• correct</li><li>• Option C: Cannot reliably detect 80 ml of free blood This statement is correct . eFAST has a limit in sensitivity and may not detect small amounts of free blood, typically below 100 ml.</li><li>• Option C: Cannot reliably detect 80 ml of free blood</li><li>• correct</li><li>• Option D: Unreliable for assessment of retroperitoneum This statement is correct . eFAST is limited in its ability to assess the retroperitoneal space due to overlying structures and the depth of the area.</li><li>• Option D: Unreliable for assessment of retroperitoneum</li><li>• correct</li><li>• Given these points, the incorrect statement regarding the utility of eFAST in trauma patients is Option B: Reliably excludes injury in penetrating trauma .</li><li>• Option B: Reliably excludes injury in penetrating trauma</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The educational objective is to understand the utility and limitations of eFAST in trauma care . eFAST is a rapid, non-invasive imaging technique that is useful during resuscitation for detecting free fluid indicative of bleeding . However, it cannot reliably exclude injury , especially in penetrating trauma , does not detect small volumes of fluid well, is not reliable for retroperitoneal assessments, and is operator-dependent.</li><li>➤ understand the utility and limitations of eFAST in trauma care</li><li>➤ eFAST is a rapid, non-invasive imaging technique</li><li>➤ useful during resuscitation for detecting free fluid</li><li>➤ bleeding</li><li>➤ exclude injury</li><li>➤ penetrating trauma</li><li>➤ Utilization of eFAST and its drawbacks :</li><li>➤ eFAST and its drawbacks</li><li>➤ Detects free fluid in the abdomen or pericardium Will not reliably detect less than 100 mL of free blood Does not directly identify injury to hollow viscus Cannot reliably exclude injury in penetrating trauma May need repeating or supplementing with other investigations Is unreliable for assessment of the retroperitoneum</li><li>➤ Detects free fluid in the abdomen or pericardium</li><li>➤ Will not reliably detect less than 100 mL of free blood</li><li>➤ Does not directly identify injury to hollow viscus</li><li>➤ Cannot reliably exclude injury in penetrating trauma</li><li>➤ May need repeating or supplementing with other investigations</li><li>➤ Is unreliable for assessment of the retroperitoneum</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 378-379.</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 378-379.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is not a part of primary survey in trauma?", "options": [{"label": "A", "text": "Checking airway patency", "correct": false}, {"label": "B", "text": "Removing clothes to inspect for wounds", "correct": false}, {"label": "C", "text": "Taking a CT scan of the patient", "correct": true}, {"label": "D", "text": "Performing basic neurological evaluation", "correct": false}], "correct_answer": "C. Taking a CT scan of the patient", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Taking a CT scan of the patient</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Checking airway patency: This is a critical component of the primary survey . Ensuring that the patient's airway is open and not compromised is essential for adequate ventilation and oxygenation.</li><li>• Option A. Checking airway patency:</li><li>• critical component of the primary survey</li><li>• Ensuring</li><li>• patient's airway is open and not compromised is essential for adequate ventilation</li><li>• Option B. Removing clothes to inspect for wounds: This is also a crucial step in the primary survey. It allows healthcare providers to assess for any external bleeding or injuries that may require immediate attention.</li><li>• Option B. Removing clothes to inspect for wounds:</li><li>• primary survey.</li><li>• healthcare providers to assess for any external bleeding</li><li>• Option D. Performing basic neurological evaluation : This is often included in the primary survey . Assessing the patient's level of consciousness, pupillary response, and motor function provides important information about potential head injuries or neurological compromise.</li><li>• Option D. Performing basic neurological evaluation</li><li>• :</li><li>• included in the primary survey</li><li>• patient's level of consciousness, pupillary response, and motor function provides</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Assessing airway , performing neurological assessment and exposure for wounds is included in primary survey . CT scan is done after stabilizing the patient .</li><li>• Assessing airway</li><li>• performing neurological assessment</li><li>• exposure for wounds</li><li>• primary survey</li><li>• CT scan is done after stabilizing the patient</li><li>• The cABCDE of trauma care</li><li>• The cABCDE of trauma care</li><li>• C – Control of massive external haemorrhage</li><li>• C</li><li>• Control</li><li>• massive external haemorrhage</li><li>• A – Airway with cervical spine protection</li><li>• A</li><li>• Airway</li><li>• B – Breathing and ventilation</li><li>• B</li><li>• Breathing</li><li>• C – Circulation and haemorrhage control: apply a pelvic binder and do not remove until a pelvic fracture is excluded</li><li>• C</li><li>• Circulation</li><li>• D – Disability (neurological status)</li><li>• D</li><li>• Disability</li><li>• E – Exposure (assess for other injuries)</li><li>• E</li><li>• Exposure</li><li>• Ref : ATLS Student Course Manual 10th Edition- Page 7-18, Bailey and Love 28 th Ed. Pg 358</li><li>• Ref</li><li>• : ATLS Student Course Manual 10th Edition- Page 7-18, Bailey and Love 28 th Ed. Pg 358</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient who met with a road traffic accident (RTA) was brought to the casualty. He is mumbling inappropriate words, opens eyes only to painful stimuli, withdraws left arm to pain and can localize pain on right arm. Calculate his GCS score:", "options": [{"label": "A", "text": "8", "correct": false}, {"label": "B", "text": "9", "correct": false}, {"label": "C", "text": "10", "correct": true}, {"label": "D", "text": "7", "correct": false}], "correct_answer": "C. 10", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/screenshot-2024-03-19-160256.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/screenshot-2024-03-19-160328.jpg"], "explanation": "<p><strong>Ans. C) 10</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• The Glasgow Coma Scale (GCS) is used to assess a patient's level of consciousness after a traumatic brain injury . The GCS is scored based on three components: eye response, verbal response, and motor response. Let's calculate the GCS score for this patient:</li><li>• Glasgow Coma Scale</li><li>• assess a patient's level of consciousness</li><li>• traumatic brain injury</li><li>• eye response, verbal response, and motor response.</li><li>• Eye Response : The patient opens eyes only to painful stimuli , which scores a 2 . Verbal Response : The patient is mumbling inappropriate words , which scores a 3 . Motor Response : The patient withdraws the left arm to pain (which is a score of 4 ), but can localise pain on the right arm (which is a higher score of 5 ). The higher score is taken, so this is a 5.</li><li>• Eye Response : The patient opens eyes only to painful stimuli , which scores a 2 .</li><li>• Eye Response</li><li>• opens eyes</li><li>• painful stimuli</li><li>• scores a 2</li><li>• Verbal Response : The patient is mumbling inappropriate words , which scores a 3 .</li><li>• Verbal Response</li><li>• mumbling inappropriate words</li><li>• scores a 3</li><li>• Motor Response : The patient withdraws the left arm to pain (which is a score of 4 ), but can localise pain on the right arm (which is a higher score of 5 ). The higher score is taken, so this is a 5.</li><li>• Motor Response</li><li>• withdraws the left arm to pain</li><li>• score of 4</li><li>• localise pain on the right arm</li><li>• higher score of 5</li><li>• Adding these together:</li><li>• Eye Response + Verbal Response + Motor Response = 2+3+5 = 10</li><li>• 2+3+5 = 10</li><li>• The patient's GCS score is 10.</li><li>• The correct answer is C. 10 .</li><li>• C. 10</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Glasgow Coma Scale (GCS) is a clinical tool used to reliably and objectively assess a patient's level of consciousness after brain injury . This patient's GCS score is calculated based on the best responses in eye , verbal , and motor categories , with the highest score in each category being used . The patient's score indicates a moderate level of injury.</li><li>➤ Glasgow Coma Scale</li><li>➤ clinical tool used to reliably and objectively assess a patient's level of consciousness after brain injury</li><li>➤ GCS score</li><li>➤ best responses in eye</li><li>➤ verbal</li><li>➤ motor categories</li><li>➤ highest score in each category being used</li><li>➤ GCS score-</li><li>➤ Ref : ATLS Student Course Manual 10th Edition Page 110</li><li>➤ Ref</li><li>➤ : ATLS Student Course Manual 10th Edition Page 110</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 363</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 363</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Calculate the GCS-P score of a patient brought into the ER with history of fall from a motorcycle. He is just making incomprehensible sounds, has a completely flexed posture and only opens his eyes to knuckle pressure. On examination, right pupil is unreactive to light:", "options": [{"label": "A", "text": "7", "correct": false}, {"label": "B", "text": "6", "correct": true}, {"label": "C", "text": "8", "correct": false}, {"label": "D", "text": "5", "correct": false}], "correct_answer": "B. 6", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) 6</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Glasgow Coma Scale-Pupils (GCS-P) is an extension of the GCS that includes the assessment of pupillary light response. It is used to evaluate the severity of brain injuries . The GCS-P score is derived by subtracting the pupillary score from the GCS score , providing a more comprehensive assessment of the patient's neurological status.</li><li>➤ Glasgow Coma Scale-Pupils</li><li>➤ extension of the GCS</li><li>➤ assessment of pupillary light response.</li><li>➤ evaluate the severity of brain injuries</li><li>➤ GCS-P score is derived by subtracting the pupillary score</li><li>➤ GCS score</li><li>➤ Ref : ATLS Student Course Manual 10th Edition Page 110</li><li>➤ Ref</li><li>➤ : ATLS Student Course Manual 10th Edition Page 110</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 363</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 363</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient was wheeled into the ER after meeting with an RTA. His parameters are BP- 90/60 mm Hg, Pulse- 112/min. After primary survey, a FAST was performed on the patient to check for signs of abdominal organ trauma. Which is the correct sequence of evaluation in this technique? Perisplenic region Perihepatic region Pericardial sac Pelvis", "options": [{"label": "A", "text": "a, b, c, d", "correct": false}, {"label": "B", "text": "b, a, c, d", "correct": false}, {"label": "C", "text": "c, a, b, d", "correct": false}, {"label": "D", "text": "c, b, a, d", "correct": true}], "correct_answer": "D. c, b, a, d", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/picture2_Cbrw9eO.jpg"], "explanation": "<p><strong>Ans. D) c, b, a, d</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• The Focused Assessment with Sonography for Trauma (FAST) examination is used in the initial assessment of trauma patients to quickly identify the presence of free fluid , which may indicate internal bleeding. The correct sequence for the FAST exam is:</li><li>• Focused Assessment with Sonography for Trauma</li><li>• initial assessment</li><li>• trauma patients</li><li>• quickly identify the presence of free fluid</li><li>• indicate internal bleeding.</li><li>• Pericardial sac : To assess for cardiac tamponade . Perihepatic region : Right upper quadrant (RUQ) to check for fluid around the liver . Perisplenic region : Left upper quadrant (LUQ) to check for fluid around the spleen . Pelvis : To assess for fluid in the pelvis which may indicate bleeding around the bladder or in the rectovesical/rectouterine pouch.</li><li>• Pericardial sac : To assess for cardiac tamponade .</li><li>• Pericardial sac</li><li>• cardiac tamponade</li><li>• Perihepatic region : Right upper quadrant (RUQ) to check for fluid around the liver .</li><li>• Perihepatic region</li><li>• fluid around the liver</li><li>• Perisplenic region : Left upper quadrant (LUQ) to check for fluid around the spleen .</li><li>• Perisplenic region</li><li>• fluid around the spleen</li><li>• Pelvis : To assess for fluid in the pelvis which may indicate bleeding around the bladder or in the rectovesical/rectouterine pouch.</li><li>• Pelvis</li><li>• fluid in the pelvis</li><li>• Given this sequence, the correct option is D. c, b, a, d</li><li>• D. c, b, a, d</li><li>• Therefore, the order of evaluation in FAST is pericardial sac first , then the perihepatic region , followed by the perisplenic region , and lastly the pelvis.</li><li>• order of evaluation in FAST is pericardial sac first</li><li>• perihepatic region</li><li>• perisplenic region</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The educational objective is to learn the correct sequence of evaluation in a FAST examination , which is a rapid bedside ultrasound technique used in trauma patients to identify free intraperitoneal fluid and pericardial effusion . The sequence is pericardial sac, perihepatic region, perisplenic region, and pelvis.</li><li>➤ correct sequence of evaluation in a FAST examination</li><li>➤ rapid bedside ultrasound technique</li><li>➤ trauma patients to identify free intraperitoneal fluid and pericardial effusion</li><li>➤ Fig: A. Probe locations. B. Fast image of the right upper quadrant showing the liver,right kidney, and free fluid.</li><li>➤ Fig:</li><li>➤ Ref : ATLS Student Course Manual 10th Edition- Page 90</li><li>➤ Ref</li><li>➤ : ATLS Student Course Manual 10th Edition- Page 90</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A young man suffered multiple severe injuries after a road traffic accident. On examination- Pulse- 100/min, BP- 84/60 mm Hg, which remains deranged despite 1 litre of bolus fluids. He is diagnosed with a pelvic fracture, tibial shaft fracture and an intra-abdominal bleed. The current approach in such severe trauma cases is Damage Control Surgery. Which of the following is not a goal of DCS?", "options": [{"label": "A", "text": "Restoring normal anatomy at the earliest", "correct": true}, {"label": "B", "text": "Stopping any active surgical bleed", "correct": false}, {"label": "C", "text": "Restoring normal physiology in the ICU", "correct": false}, {"label": "D", "text": "Controlling contamination", "correct": false}], "correct_answer": "A. Restoring normal anatomy at the earliest", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Restoring normal anatomy at the earliest</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Restoring normal anatomy at the earliest This is not the immediate goal of DCS . While eventual restoration of normal anatomy is a goal, the initial focus of DCS is on stabilization, not immediate definitive repair.</li><li>• Restoring normal anatomy at the earliest</li><li>• not the immediate goal of DCS</li><li>• initial focus of DCS is on stabilization,</li><li>• Damage Control Surgery (DCS) is a strategy used in the management of critically injured patients , particularly those with severe trauma who are at risk for the lethal triad of hypothermia, acidosis, and coagulopathy . The primary goal is to prioritize the patient's physiological status over anatomical repair to increase survival rates. The goals of DCS include:</li><li>• Damage Control Surgery</li><li>• strategy used in the management of critically injured patients</li><li>• severe trauma who are at risk for the lethal triad</li><li>• hypothermia, acidosis, and coagulopathy</li><li>• Stopping any active surgical bleed : Immediate control of hemorrhage is crucial to prevent further deterioration of the patient's condition. Controlling contamination : This includes controlling spillage from gastrointestinal injuries or other sources of contamination. Restoring normal physiology in the ICU : Before definitive surgical repair, the priority is to stabilize the patient's physiological parameters in the ICU , correcting hypothermia, acidosis, and coagulopathy.</li><li>• Stopping any active surgical bleed : Immediate control of hemorrhage is crucial to prevent further deterioration of the patient's condition.</li><li>• Stopping any active surgical bleed</li><li>• Immediate control of hemorrhage</li><li>• Controlling contamination : This includes controlling spillage from gastrointestinal injuries or other sources of contamination.</li><li>• Controlling contamination</li><li>• controlling spillage from gastrointestinal injuries</li><li>• Restoring normal physiology in the ICU : Before definitive surgical repair, the priority is to stabilize the patient's physiological parameters in the ICU , correcting hypothermia, acidosis, and coagulopathy.</li><li>• Restoring normal physiology in the ICU</li><li>• the priority is to stabilize the patient's physiological parameters in the ICU</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ To understand the principles and goals of Damage Control Surgery in the context of severe trauma . DCS prioritizes the stabilization of the patient's physiological state and control of life-threatening conditions over immediate anatomical reconstruction.</li><li>➤ principles and goals of Damage Control Surgery</li><li>➤ severe trauma</li><li>➤ DCS prioritizes the stabilization of the patient's physiological state</li><li>➤ control of life-threatening conditions</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition- Page 385, 386</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition- Page 385, 386</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient was rushed into the ER following an RTA. Primary survey was done and following initial imaging, he was diagnosed with a pelvic fracture with abdominal solid organ injury. Which of the following lab workups done as adjuncts to primary survey would prompt you to take an ‘Early Total Care’ approach instead of a ‘Damage Control Surgery’?", "options": [{"label": "A", "text": "Coagulopathy", "correct": false}, {"label": "B", "text": "pH of 7.14", "correct": false}, {"label": "C", "text": "Serum lactate = 1.8 mmol/ L", "correct": true}, {"label": "D", "text": "Temp of 33.5’C", "correct": false}], "correct_answer": "C. Serum lactate = 1.8 mmol/ L", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Serum lactate = 1.8 mmol/ L</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Coagulopathy Coagulopathy is an indication for DCS as it is a part of the 'lethal triad' and indicates a decline in physiological reserve.</li><li>• Option A: Coagulopathy</li><li>• indication for DCS as it is a part of the 'lethal triad'</li><li>• Option B: pH of 7.14 A pH of 7.14 indicates acidosis, which is also an indication for DCS .</li><li>• Option B: pH of 7.14</li><li>• indicates acidosis, which is also an indication for DCS</li><li>• Option D: Temp of 33.5°C A temperature of 33.5°C indicates mild hypothermia and could be an indication for DCS , as hypothermia is a component of the 'lethal triad' .</li><li>• Option D: Temp of 33.5°C</li><li>• 33.5°C indicates mild hypothermia</li><li>• indication for DCS</li><li>• hypothermia is a component of the 'lethal triad'</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ To distinguish between patients who are candidates for Damage Control Surgery versus those who may benefit from an Early Total Care approach. Indicators of the need for DCS include severe physiological derangement , part of which can be detected through abnormal laboratory values such as coagulopathy, acidosis, hypothermia, high lactate levels, and other factors indicating a decline in physiological reserve. A normal lactate level is more indicative of a patient who may tolerate a more definitive surgical care approach.</li><li>➤ distinguish between patients who are candidates for Damage Control Surgery versus those who may benefit from an Early Total Care approach.</li><li>➤ Indicators of the need for DCS</li><li>➤ severe physiological derangement</li><li>➤ Early Total Care (ETC) versus Damage Control Surgery (DCS)</li><li>➤ Early Total Care (ETC) versus Damage Control Surgery (DCS)</li><li>➤ ETC describes the definitive management of a patient’s injuries within 36 hours of injury after a period of initial resuscitation DCS describes simultaneous resuscitation with early rapid lifeand limb-saving surgery. Time-consuming definitive surgery is deferred until the patient’s physiological status allows An ETC approach can be changed to a damage control approach if the patient’s physiology deteriorates during definitive surgery</li><li>➤ ETC describes the definitive management of a patient’s injuries within 36 hours of injury after a period of initial resuscitation</li><li>➤ DCS describes simultaneous resuscitation with early rapid lifeand limb-saving surgery. Time-consuming definitive surgery is deferred until the patient’s physiological status allows</li><li>➤ An ETC approach can be changed to a damage control approach if the patient’s physiology deteriorates during definitive surgery</li><li>➤ Venous lactate is an essential marker of resuscitation.</li><li>➤ Venous lactate is an essential marker of resuscitation.</li><li>➤ &lt;2 mmol/L – ETC 2–3 mmol/L – look at the trend (increasing or decreasing) 3 mmol/L – may be under-resuscitated; should either have further resuscitation or DCS if surgery is urgent &gt;5 mmol/L – DCS</li><li>➤ &lt;2 mmol/L – ETC</li><li>➤ 2–3 mmol/L – look at the trend (increasing or decreasing)</li><li>➤ 3 mmol/L – may be under-resuscitated; should either have further resuscitation or DCS if surgery is urgent</li><li>➤ &gt;5 mmol/L – DCS</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition- Page 358-359, 386</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition- Page 358-359, 386</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A motorcyclist, Mr. X, was brought into the ER after an RTA. There was no sign of any penetrating injury. His vitals were- BP- 86/60 mm Hg, Pulse- 102/min. At the same time, another patient, Mr. Y, a professional boxer, was also brought following a blow to the abdomen. Mr. Y’s vitals were- BP-112/72 mm Hg, Pulse- 86/min. His abdomen was tender on palpation. Which is the next modality that you would advise in the case of Mr. X and Mr. Y respectively?", "options": [{"label": "A", "text": "CECT for both", "correct": false}, {"label": "B", "text": "FAST for Mr. X, exploratory laparotomy for Mr. Y", "correct": false}, {"label": "C", "text": "CECT for Mr. X, exploratory laparotomy for Mr. Y", "correct": false}, {"label": "D", "text": "FAST for Mr. X, CECT for Mr. Y", "correct": true}], "correct_answer": "D. FAST for Mr. X, CECT for Mr. Y", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) FAST for Mr. X, CECT for Mr. Y</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: CECT for both Contrast-Enhanced Computed Tomography (CECT) is detailed and the gold standard for abdominal imaging but is time-consuming and requires a stable patient . It would not be ideal for Mr. X, who is hemodynamically unstable.</li><li>• Option A: CECT for both</li><li>• Contrast-Enhanced Computed Tomography</li><li>• detailed and the gold standard for abdominal imaging</li><li>• time-consuming and requires a stable patient</li><li>• Option B: FAST for Mr. X, exploratory laparotomy for Mr. Y Exploratory laparotomy is a surgical intervention and not a first-line diagnostic modality . It's reserved for when there is clear evidence of a need for surgery, and there is typically an attempt to confirm the injury through less invasive means first.</li><li>• Option B: FAST for Mr. X, exploratory laparotomy for Mr. Y</li><li>• Exploratory laparotomy</li><li>• surgical intervention</li><li>• not a first-line diagnostic modality</li><li>• Option C: CECT for Mr. X, exploratory laparotomy for Mr. Y This option is not suitable for Mr. X , who is hemodynamically unstable and may not tolerate the delay or the procedure of CECT. For Mr. Y, exploratory laparotomy might be premature without imaging confirmation.</li><li>• Option C: CECT for Mr. X, exploratory laparotomy for Mr. Y</li><li>• not suitable for Mr. X</li><li>• hemodynamically unstable</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ To understand the appropriate use of diagnostic modalities in trauma care . FAST is used for rapid assessment of hemodynamically unstable patients to detect free intra-abdominal fluid . In contrast, CECT is reserved for stable patients requiring detailed abdominal imaging. The choice of diagnostic tool must be aligned with the patient's stability and the nature of the injury.</li><li>➤ appropriate use of diagnostic modalities in trauma care</li><li>➤ FAST</li><li>➤ rapid assessment of hemodynamically unstable patients to detect free intra-abdominal fluid</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition - Page 379.</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition - Page 379.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "After having completed primary survey of a patient of RTA and sending all relevant blood investigations, securing 2 large bore iv lines, checking vitals and catheterizing the patient, the doctor moves on to seek some additional history. Which of these questions form a part of this next history taking?", "options": [{"label": "A", "text": "Time of last meal", "correct": false}, {"label": "B", "text": "Any known allergies", "correct": false}, {"label": "C", "text": "Events that led to the trauma", "correct": false}, {"label": "D", "text": "All of the above", "correct": true}], "correct_answer": "D. All of the above", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) All of the above</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Time of last meal Knowing the time of the last meal helps assess the risk of aspiration and informs decisions about the timing of surgery if needed.</li><li>• Option A: Time of last meal</li><li>• helps assess the risk of aspiration and informs decisions</li><li>• Option B: Any known allergies It's essential to know about any allergies the patient may have , especially to medications, which may influence the choice of drugs used for treatment.</li><li>• Option B: Any known allergies</li><li>• know about any allergies the patient may have</li><li>• Option C: Events that led to the trauma Understanding the mechanism of injury can provide crucial information about potential injuries , even those that are not immediately apparent.</li><li>• Option C: Events that led to the trauma</li><li>• mechanism of injury can provide crucial information about potential injuries</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ To understand the components of history taking during the secondary survey in trauma care . This includes assessing for allergies , medications currently used , past illnesses or pregnancies, the last meal, and the events or environment related to the injury . All these aspects can have significant implications for patient care and management, making them critical components of the secondary survey.</li><li>➤ components of history taking during the secondary survey in trauma care</li><li>➤ assessing for allergies</li><li>➤ medications currently used</li><li>➤ past illnesses or pregnancies,</li><li>➤ last meal, and the events or environment related to the injury</li><li>➤ A : Allergies</li><li>➤ A</li><li>➤ M : Medication – important to ask about anticoagulant and antiplatelet therapies, corticosteroid use and any possible immunosuppressive treatment</li><li>➤ M</li><li>➤ P : Past medical and surgical history – has the patient had an anaesthetic in the past and were there any complications</li><li>➤ P</li><li>➤ L : Last meal – something to eat or drink</li><li>➤ L</li><li>➤ E : Events – events that led to the injury</li><li>➤ E</li><li>➤ Ref : ATLS Student Course Manual 10th Edition- Page 13.</li><li>➤ Ref</li><li>➤ : ATLS Student Course Manual 10th Edition- Page 13.</li><li>➤ Bailey 28 th Ed. Pg 416-417.</li><li>➤ Bailey 28 th Ed. Pg 416-417.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient of RTA having sustained a head injury was brought into casualty. He was confused, opened his eyes to sounds and showed withdrawal to pain. Classify his injury based on his GCS score?", "options": [{"label": "A", "text": "Minor head injury", "correct": false}, {"label": "B", "text": "Mild head injury", "correct": false}, {"label": "C", "text": "Moderate head injury", "correct": true}, {"label": "D", "text": "Severe head injury", "correct": false}], "correct_answer": "C. Moderate head injury", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/screenshot-2024-03-19-160606.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/screenshot-2024-03-19-160812.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/screenshot-2024-03-19-161020.jpg"], "explanation": "<p><strong>Ans. C) Moderate head injury</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• On calculating the Glasgow Coma Score for this patient,</li><li>• Eye opening- to sound – 3</li><li>• Eye opening- to sound – 3</li><li>• V- confused – 4</li><li>• V- confused – 4</li><li>• M- withdrawal to pain – 4</li><li>• M- withdrawal to pain – 4</li><li>• Total = 11</li><li>• 11</li><li>• Based on the GCS score:</li><li>• Therefore, with a total score of 11 , the patient would be classified as having a moderate head injury.</li><li>• total score of 11</li><li>• Best predictor of neurological outcome is motor response.</li><li>• GCS score</li><li>• A new parameter called pupil reactivity score has been added, making it GCS-P. It denotes ‘pupils unreactive to light’. The pupillary score needs to be subtracted from GCS score to obtain final GCS-P value. Thus, the range for GCS-P is 1-15.</li><li>• Ref : ATLS Student Course Manual 10th Edition Page 110</li><li>• Ref : ATLS Student Course Manual 10th Edition Page 110</li><li>• Bailey and Love’s Short Practice of Surgery 28th Edition Page 361-363</li><li>• Bailey and Love’s Short Practice of Surgery 28th Edition Page 361-363</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In patients of head injury, brain perfusion and intracranial pressure dynamics are explained with the principle that ‘the total volume of the intracranial contents must remain constant, because the cranium is a rigid container incapable of expanding’. On these lines, read the following statements and choose the incorrect one: CPP is Cerebral perfusion pressure, SBP is systolic BP, ICP is intracranial pressure.", "options": [{"label": "A", "text": "CPP = SBP - ICP", "correct": true}, {"label": "B", "text": "This doctrine is called the Monro- Kellie doctrine", "correct": false}, {"label": "C", "text": "Initially after head injury, a clot may expand without rise in ICP due to pressure buffering by compressing venous blood and CSF out", "correct": false}, {"label": "D", "text": "After severe head injury, regional or global cerebral ischemia may ensue if auto regulation of CPP is lost", "correct": false}], "correct_answer": "A. CPP = SBP - ICP", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/picture4_xj6jO3X.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/picture5_vHmQQ5L.jpg"], "explanation": "<p><strong>Ans. A) CPP = SBP – ICP</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: This doctrine is called the Monro-Kellie doctrine . This is correct . The Monro-Kellie doctrine states that the sum of the volumes of the brain , CSF , and intracranial blood is constant , and an increase in one must be compensated by a decrease in one or both of the others within the closed cranial compartment.</li><li>• Option B:</li><li>• Monro-Kellie doctrine</li><li>• correct</li><li>• Monro-Kellie doctrine states that the sum of the volumes of the brain</li><li>• CSF</li><li>• intracranial blood is constant</li><li>• Option C: Initially after head injury , a clot may expand without a rise in ICP due to pressure buffering by compressing venous blood and CSF out . This is correct . The initial compensation for an increase in volume within the skull (like a hematoma) may occur without a significant rise in ICP due to displacement of blood and CSF.</li><li>• Option C:</li><li>• after head injury</li><li>• clot may expand without a rise in ICP</li><li>• pressure buffering by compressing venous blood and CSF out</li><li>• correct</li><li>• Option D: After severe head injury , regional or global cerebral ischemia may ensue if autoregulation of CPP is lost . This is correct . Autoregulation maintains consistent cerebral blood flow despite fluctuations in systemic blood pressure. Loss of this function can lead to ischemia.</li><li>• Option D:</li><li>• After severe head injury</li><li>• regional or global cerebral ischemia may ensue if autoregulation of CPP is lost</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The cerebral perfusion pressure (CPP) is correctly calculated as the mean arterial pressure (MAP) minus the intracranial pressure (ICP). Understanding CPP and the</li><li>➤ cerebral perfusion pressure</li><li>➤ correctly calculated as the mean arterial pressure</li><li>➤ minus the intracranial pressure</li><li>➤ Monro-Kellie doctrine is crucial in the management of head injuries to ensure adequate cerebral blood flow and avoid secondary brain injury.Top of FormBottom of Form</li><li>➤ Fig: Volume-Pressure Curve. The intracranial contents initially can compensate for a new intracranial mass, such as a subdural or epidural hematoma. Once the volume of this mass reaches a critical threshold, a rapid increase in ICP often occurs, which can lead to reduction or cessation of cerebral blood flow.</li><li>➤ Fig:</li><li>➤ Fig: The Monro-Kellie Doctrine Regarding Intracranial Compensation for Expanding Mass. The total volume of the intracranial contents remains constant. If the addition of a mass such as a hematoma compresses an equal volume of CSF and venous blood, ICP remains normal. However, when this compensatory mechanism is exhausted, ICP increases exponentially for even a small additional increase in hematoma volume.</li><li>➤ Fig:</li><li>➤ Ref : ATLS Student Manual 10th Edition Page 107, 108</li><li>➤ Ref</li><li>➤ : ATLS Student Manual 10th Edition Page 107, 108</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the components of the Cushing’s triad in brain herniation?", "options": [{"label": "A", "text": "Hypertension, tachycardia, irregular respiration", "correct": false}, {"label": "B", "text": "Hypotension, tachycardia, irregular respiration", "correct": false}, {"label": "C", "text": "Hypotension, bradycardia, irregular respiration", "correct": false}, {"label": "D", "text": "Hypertension, bradycardia, irregular respiration", "correct": true}], "correct_answer": "D. Hypertension, bradycardia, irregular respiration", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D. Hypertension, bradycardia, irregular respiration</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Cushing's triad is a clinical syndrome often seen in the setting of increased intracranial pressure (ICP) that can lead to brain herniation , particularly cerebellar tonsillar herniation through the foramen magnum . It is characterized by three primary signs:</li><li>• Cushing's triad</li><li>• clinical syndrome often seen in the setting of increased intracranial pressure</li><li>• lead to brain herniation</li><li>• cerebellar tonsillar herniation</li><li>• foramen magnum</li><li>• Hypertension : The body increases systemic blood pressure to attempt to overcome the increased ICP and maintain cerebral perfusion. Bradycardia : As a reflex response to hypertension, the body activates the parasympathetic system, which slows down the heart rate. Irregular Respiration : Due to pressure on the brainstem, particularly the medullary vasomotor and respiratory centers, respiratory patterns become erratic.</li><li>• Hypertension : The body increases systemic blood pressure to attempt to overcome the increased ICP and maintain cerebral perfusion.</li><li>• Hypertension</li><li>• Bradycardia : As a reflex response to hypertension, the body activates the parasympathetic system, which slows down the heart rate.</li><li>• Bradycardia</li><li>• Irregular Respiration : Due to pressure on the brainstem, particularly the medullary vasomotor and respiratory centers, respiratory patterns become erratic.</li><li>• Irregular Respiration</li><li>• The correct answer is indeed D. Hypertension, bradycardia, irregular respiration .</li><li>• D. Hypertension, bradycardia, irregular respiration</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ The educational objective is to recognize Cushing's triad (hypertension, bradycardia, irregular respiration) as a sign of increased intracranial pressure and impending brain herniation , which requires immediate medical intervention to prevent brainstem death .</li><li>➤ recognize Cushing's triad</li><li>➤ sign of increased intracranial pressure</li><li>➤ impending brain herniation</li><li>➤ requires immediate medical intervention</li><li>➤ prevent brainstem death</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 361</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 361</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 1-year-old child was brought to the casualty with multiple injuries, including head injury. He cries in response to pain. What is his verbal response score?", "options": [{"label": "A", "text": "2", "correct": false}, {"label": "B", "text": "3", "correct": true}, {"label": "C", "text": "4", "correct": false}, {"label": "D", "text": "1", "correct": false}], "correct_answer": "B. 3", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/screenshot-2024-03-19-175454.jpg"], "explanation": "<p><strong>Ans. B) 3</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Paediatric Glasgow Coma Scale , used for patients under the age of 2 years -</li><li>• Paediatric Glasgow Coma Scale</li><li>• patients under the age of 2 years</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The pediatric Glasgow Coma Scale is used for children under 2 years of age .</li><li>➤ pediatric Glasgow Coma Scale</li><li>➤ children under 2 years of age</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 370</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 370</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient of motorcycle accident sustained a head injury. He fell unconscious, later regained his consciousness temporarily but was now worsening neurologically. His CT scan is given below. What is the most likely diagnosis?", "options": [{"label": "A", "text": "Extradural haemorrhage", "correct": true}, {"label": "B", "text": "Subdural haemorrhage", "correct": false}, {"label": "C", "text": "Intra-parenchymal bleed", "correct": false}, {"label": "D", "text": "Subarachnoid haemorrhage", "correct": false}], "correct_answer": "A. Extradural haemorrhage", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/picture6_RLDsThy.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/picture7_kxaStZo.jpg"], "explanation": "<p><strong>Ans. A) Extradural haemorrhage</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Subdural Hemorrhage A subdural hemorrhage (SDH) is typically seen as a crescent-shaped hyperdensity that can cross suture lines but not cross the midline due to the dural attachment at the falx cerebri. It usually results from venous bleeding, and the clinical presentation can vary from acute to chronic, without the classic lucid interval seen in EDH.</li><li>• Option B: Subdural Hemorrhage</li><li>• seen as a crescent-shaped hyperdensity</li><li>• cross suture lines</li><li>• not cross the midline</li><li>• Option C: Intra-parenchymal Bleed an intra-parenchymal bleed, or intracerebral hemorrhage , is bleeding within the brain tissue itself and appears on CT as a hyperdense area within the parenchyma, often with surrounding edema. The clinical presentation typically does not involve a lucid interval. The scan provided does not show the typical signs of an intra-parenchymal bleed.</li><li>• Option C: Intra-parenchymal Bleed</li><li>• intracerebral hemorrhage</li><li>• bleeding within the brain tissue itself</li><li>• appears on CT as a hyperdense area</li><li>• Option D: Subarachnoid Hemorrhage A subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space , where cerebrospinal fluid circulates . On CT, this appears as increased density in the sulci or cisterns around the brain , often described as a “star-shaped” pattern . The history of trauma followed by a lucid interval is not characteristic of SAH. The provided scan does not show the typical diffuse pattern of increased density in the subarachnoid space that would indicate SAH.</li><li>• Option D: Subarachnoid Hemorrhage</li><li>• bleeding into the subarachnoid space</li><li>• cerebrospinal fluid circulates</li><li>• appears as increased density in the sulci or cisterns around the brain</li><li>• “star-shaped” pattern</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The correct diagnosis in a patient who experiences a lucid interval following a head injury , and whose CT scan shows a lens-shaped hyperdensity adjacent to the skull , is an extradural hemorrhage (EDH). This condition is a neurosurgical emergency and requires immediate attention to prevent further neurological compromise.</li><li>➤ lucid interval</li><li>➤ head injury</li><li>➤ CT scan shows a lens-shaped hyperdensity adjacent to the skull</li><li>➤ extradural hemorrhage</li><li>➤ Extradural hematomas are most often located in the temporal or temporo-parietal regions and often result from a tear of the middle meningeal artery due to a fracture. These clots are classically arterial in origin; however, they also may result from disruption of a major venous sinus or bleeding from a skull fracture. The classic presentation of an epidural hematoma is with a lucid interval between the time of injury and neurological impairment. Uncal herniation due to EDH may present as contralateral hemiparesis and ipsilateral pupillary dilatation along with reduced level of consciousness.</li><li>➤ Extradural hematomas are most often located in the temporal or temporo-parietal regions and often result from a tear of the middle meningeal artery due to a fracture. These clots are classically arterial in origin; however, they also may result from disruption of a major venous sinus or bleeding from a skull fracture.</li><li>➤ The classic presentation of an epidural hematoma is with a lucid interval between the time of injury and neurological impairment.</li><li>➤ The classic presentation of an epidural hematoma is with a lucid interval between the time of injury and neurological impairment.</li><li>➤ Uncal herniation due to EDH may present as contralateral hemiparesis and ipsilateral pupillary dilatation along with reduced level of consciousness.</li><li>➤ Management: It is a neurosurgical emergency. Significant EDH mandates urgent transfer to the most accessible neurosurgical facility for immediate evacuation in deteriorating or comatose patients or those with large bleeds, and for close observation with serial imaging in other cases.</li><li>➤ Management: It is a neurosurgical emergency.</li><li>➤ Management:</li><li>➤ Significant EDH mandates urgent transfer to the most accessible neurosurgical facility for immediate evacuation in deteriorating or comatose patients or those with large bleeds, and for close observation with serial imaging in other cases.</li><li>➤ immediate evacuation in deteriorating or comatose patients</li><li>➤ Ref : ATLS Student Manual 10th Edition Page 111</li><li>➤ Ref</li><li>➤ : ATLS Student Manual 10th Edition Page 111</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 365</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 365</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 75-year-old man presented to the OPD with mild headache, vomiting, and features of raised ICP. There was no history of any trauma in the last few hours. His son revealed that the man had slipped and fallen in the bathroom a month back and had hit his head back then. He is currently on warfarin because he has had a mechanical valve replacement in the past. What is the diagnosis?", "options": [{"label": "A", "text": "Acute subdural haemorrhage", "correct": false}, {"label": "B", "text": "Chronic subdural haemorrhage", "correct": true}, {"label": "C", "text": "Subarachnoid haemorrhage", "correct": false}, {"label": "D", "text": "Intra - parenchymal bleed", "correct": false}], "correct_answer": "B. Chronic subdural haemorrhage", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Chronic subdural haemorrhage</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Acute Subdural Hemorrhage an acute subdural hemorrhage typically presents shortly after an event that causes significant head trauma . On imaging, it appears as a crescent-shaped hyperdensity adjacent to the skull. The patient’s symptoms and the timing (a month after a fall) make an acute subdural hemorrhage less likely in this case.</li><li>• Option A. Acute Subdural Hemorrhage</li><li>• shortly after an event that causes significant head trauma</li><li>• Option C. Subarachnoid Hemorrhage A subarachnoid hemorrhage often presents acutely with a severe headache ('thunderclap headache'), and while it can lead to increased ICP , the lack of recent acute trauma and the patient's clinical presentation over a longer period make this diagnosis less likely. Imaging would show blood within the subarachnoid space, often around the brain or within the sulci.</li><li>• Option C. Subarachnoid Hemorrhage</li><li>• presents acutely with a severe headache</li><li>• it can lead to increased ICP</li><li>• lack of recent acute trauma</li><li>• patient's clinical presentation</li><li>• Option D. Intra-parenchymal Bleed an intra-parenchymal bleed is typically associated with high blood pressure, trauma, or vascular anomalies , presenting acutely with focal neurological deficits and signs of ICP elevation . Given the patient’s history and presentation, this is also less likely than a chronic subdural hemorrhage.</li><li>• Option D. Intra-parenchymal Bleed</li><li>• associated with high blood pressure, trauma, or vascular anomalies</li><li>• acutely with focal neurological deficits</li><li>• signs of ICP elevation</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In an elderly patient on anticoagulation presenting with headache, vomiting, and features of raised ICP weeks after a minor trauma , the diagnosis is most likely chronic subdural hemorrhage. This condition is characterized by the stretching and tearing of bridging veins in the subdural space , particularly in the context of cerebral atrophy and anticoagulant use , leading to a collection of blood that can gradually increase in size and cause symptoms due to mass effect.</li><li>➤ elderly patient on anticoagulation</li><li>➤ headache, vomiting,</li><li>➤ raised ICP weeks after a minor trauma</li><li>➤ chronic subdural hemorrhage.</li><li>➤ stretching and tearing of bridging veins in the subdural space</li><li>➤ cerebral atrophy and anticoagulant use</li><li>➤ collection of blood</li><li>➤ increase in size and cause symptoms due to mass effect.</li><li>➤ On presentation it is important to exclude coexisting electrolyte disturbance and infections, which may contribute to clinical impairment. Imaging reveals diffuse hypo-density overlying the brain surface. Recent bleeding may be iso- dense or hyper-dense, and mixed density can indicate an acute-on-chronic subdural hematoma. Anticoagulation should be reversed, either by administration of vitamin K or urgently by transfusion of recombinant clotting factors in patients who have deteriorated acutely. Conservative management, sometimes with administration of corticosteroids, can be considered for small bleeds without symptoms or with headache alone. For the majority drainage is performed using burr holes. Urgency is dictated by the clinical condition of the patient and imaging evidence of mass effect .</li><li>➤ On presentation it is important to exclude coexisting electrolyte disturbance and infections, which may contribute to clinical impairment. Imaging reveals diffuse hypo-density overlying the brain surface. Recent bleeding may be iso- dense or hyper-dense, and mixed density can indicate an acute-on-chronic subdural hematoma.</li><li>➤ Anticoagulation should be reversed, either by administration of vitamin K or urgently by transfusion of recombinant clotting factors in patients who have deteriorated acutely.</li><li>➤ Conservative management, sometimes with administration of corticosteroids, can be considered for small bleeds without symptoms or with headache alone.</li><li>➤ For the majority drainage is performed using burr holes. Urgency is dictated by the clinical condition of the patient and imaging evidence of mass effect .</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 367</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 367</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient of a massive RTA was admitted and continued to stay comatose despite CT scan of brain revealing no abnormal findings. MRI brain was done and revealed the following picture. What is the most likely diagnosis?", "options": [{"label": "A", "text": "Acute subdural haemorrhage", "correct": false}, {"label": "B", "text": "Intra-ventricular bleed", "correct": false}, {"label": "C", "text": "Diffuse axonal injury", "correct": true}, {"label": "D", "text": "Extradural haemorrhage", "correct": false}], "correct_answer": "C. Diffuse axonal injury", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/picture10_dyIU2m0.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/picture11_Hi1fJNe.jpg"], "explanation": "<p><strong>Ans. C) Diffuse axonal injury</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Acute Subdural Hemorrhage This condition usually presents on a CT scan as a crescent-shaped hyperdensity along the brain's convexity . The patient's presentation of coma without CT findings makes acute subdural hemorrhage less likely.</li><li>• Option A: Acute Subdural Hemorrhage</li><li>• CT scan as a crescent-shaped hyperdensity along the brain's convexity</li><li>• Option B: Intra-ventricular Bleed An intra-ventricular bleed would be seen on a CT scan as hyperdensity within the ventricles and could cause hydrocephalus , leading to coma . However, this would generally be apparent on a CT scan, making this option less likely given the normal CT findings.</li><li>• Option B: Intra-ventricular Bleed</li><li>• CT scan as hyperdensity within the ventricles and could cause hydrocephalus</li><li>• leading to coma</li><li>• Option D: Extradural Hemorrhage Extradural hemorrhage, or epidural hematoma, is typically associated with a lens-shaped hyperdensity on CT imaging , often related to arterial bleeding and associated with skull fractures. It typically presents with a lucid interval followed by deterioration, which is not described in the scenario provided.</li><li>• Option D: Extradural Hemorrhage</li><li>• lens-shaped hyperdensity on CT imaging</li><li>• arterial bleeding and associated with skull fractures.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In a patient presenting with coma after a high-energy trauma , with a normal CT scan but abnormal findings on MRI , the most likely diagnosis is diffuse axonal injury (DAI). DAI is characterized by shearing forces at the grey-white matter junction , leading to axonal damage and microscopic hemorrhages that may not be visible on CT imaging.</li><li>➤ presenting with coma after a high-energy trauma</li><li>➤ normal CT scan</li><li>➤ abnormal findings on MRI</li><li>➤ diffuse axonal injury</li><li>➤ DAI</li><li>➤ characterized by shearing forces at the grey-white matter junction</li><li>➤ axonal damage</li><li>➤ microscopic hemorrhages</li><li>➤ Axons are injured directly by mechanical forces , with subsequent alterations in axoplasmic flow and axonal swelling. The swelling is best demonstrated with silver impregnation techniques or with immunoperoxidase stains for axonally transported proteins , such as amyloid precursor protein and α -synuclein . Later, increased numbers of microglia are seen in damaged areas of the cerebral cortex, and subsequently there is degeneration of the involved fibre tracts. Retraction balls are seen.</li><li>➤ Axons are injured directly by mechanical</li><li>➤ forces</li><li>➤ subsequent alterations in axoplasmic flow and axonal swelling.</li><li>➤ silver impregnation techniques or with immunoperoxidase stains for axonally transported proteins</li><li>➤ amyloid precursor</li><li>➤ protein and</li><li>➤ α</li><li>➤ -synuclein</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 368</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 368</li><li>➤ ATLS Student Manual 10th Edition Page 110</li><li>➤ ATLS Student Manual 10th Edition Page 110</li><li>➤ Robbins and Cotran’s Pathologic Basis of Disease 10th Edition Page 1250.</li><li>➤ Robbins and Cotran’s Pathologic Basis of Disease 10th Edition Page 1250.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A teenager was brought into the casualty following a fall during a football match, with complaints of amnesia, confusion and headache but no loss of consciousness. His GCS was 14/15. CT scan brain showed no abnormality. What is the likely diagnosis?", "options": [{"label": "A", "text": "Concussion", "correct": true}, {"label": "B", "text": "Diffuse axonal injury", "correct": false}, {"label": "C", "text": "Lucid interval", "correct": false}, {"label": "D", "text": "Subdural haemorrhage", "correct": false}], "correct_answer": "A. Concussion", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Concussion</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Diffuse Axonal Injury Diffuse axonal injury (DAI) is a severe form of brain injury that occurs with intense rotational forces , often seen in high-velocity car accidents or severe falls . It can cause microscopic brain lesions that may not be evident on a CT scan but are more often associated with a lower GCS score and loss of consciousness.</li><li>• Option B: Diffuse Axonal Injury</li><li>• severe form of brain injury that occurs with intense rotational forces</li><li>• high-velocity car accidents or severe falls</li><li>• Option C: Lucid interval: It is seen in EDH . EDH typically presents with a lucid interval followed by a decline in consciousness and is usually associated with a fracture of the temporal bone . This condition often shows a lens-shaped bleed on a CT scan, which was not present in this case.</li><li>• Option C: Lucid interval:</li><li>• seen in EDH</li><li>• EDH</li><li>• lucid interval followed by a decline in consciousness</li><li>• associated with a fracture of the temporal bone</li><li>• Option D: Subdural Hemorrhage A subdural hemorrhage is a collection of blood between the dura and the brain tissue. It usually results from tearing of bridging veins and presents with a fluctuating level of consciousness and focal neurological signs . Like extradural hemorrhages, subdural hemorrhages are usually visible on a CT scan.</li><li>• Option D: Subdural Hemorrhage</li><li>• collection of blood between the dura and the brain tissue.</li><li>• tearing of bridging veins and presents with a fluctuating level of consciousness and focal neurological signs</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Concussion is a clinical diagnosis characterized by symptoms such as headache, confusion, and amnesia following head trauma , often without imaging abnormalities . It is important to note that loss of consciousness is not required for the diagnosis of concussion.</li><li>➤ Concussion is a clinical diagnosis</li><li>➤ headache, confusion, and amnesia following head trauma</li><li>➤ without imaging abnormalities</li><li>➤ Top of Form</li><li>➤ Concussion is mild head injury without imaging abnormalities : loss of consciousness at the time of injury is not a prerequisite. Key features include confusion and amnesia. The patient may be lethargic, easily distractable, forgetful, slow to interact or emotionally labile. Gait disturbance and incoordination may be seen. Post-concussive syndrome is a loosely defined constellation of symptoms persisting for a prolonged period after injury . Patients may report somatic features such as headache, dizziness and disorders of hearing and vision. They may also suffer a variety of neurocognitive and neuropsychological disturbances, including difficulty with concentration and recall, insomnia, emotional lability, fatigue, depression and personality change.</li><li>➤ Concussion is mild head injury without imaging abnormalities : loss of consciousness at the time of injury is not a prerequisite. Key features include confusion and amnesia. The patient may be lethargic, easily distractable, forgetful, slow to interact or emotionally labile. Gait disturbance and incoordination may be seen.</li><li>➤ Concussion</li><li>➤ mild head injury without imaging abnormalities</li><li>➤ Post-concussive syndrome is a loosely defined constellation of symptoms persisting for a prolonged period after injury . Patients may report somatic features such as headache, dizziness and disorders of hearing and vision. They may also suffer a variety of neurocognitive and neuropsychological disturbances, including difficulty with concentration and recall, insomnia, emotional lability, fatigue, depression and personality change.</li><li>➤ Post-concussive syndrome is a loosely defined constellation of symptoms persisting for a prolonged period after injury</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 362.</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 362.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Read the following statements regarding cerebral contusions and choose whether they are true or false: Most commonly occur in frontal and temporal lobes. Cannot occur at any site except the site of impact. A single CT scan head is enough to assess overall extent of these injuries, no serial imaging required.", "options": [{"label": "A", "text": "T F T", "correct": false}, {"label": "B", "text": "F F T", "correct": false}, {"label": "C", "text": "F T T", "correct": false}, {"label": "D", "text": "T F F", "correct": true}], "correct_answer": "D. T F F", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Statement 1: Most commonly occur in frontal and temporal lobes. This statement is true . Cerebral contusions commonly occur in the frontal and temporal lobes. These areas are more vulnerable to contusions due to their location near bony protrusions within the skull.</li><li>• Statement 1: Most commonly occur in frontal and temporal lobes.</li><li>• true</li><li>• Statement 2: Cannot occur at any site except the site of impact. This statement is false . Contusions can occur both at the site of impact (coup injury) and on the opposite side of the brain (contrecoup injury), especially in cases of acceleration-deceleration injuries where the brain moves within the skull.</li><li>• Statement 2: Cannot occur at any site except the site of impact.</li><li>• false</li><li>• Contusions</li><li>• occur both at the site of impact</li><li>• the opposite side of the brain</li><li>• Statement 3: A single CT scan head is enough to assess overall extent of these injuries, no serial imaging required. This statement is false . The extent of cerebral contusions may not be fully apparent on initial imaging . Serial imaging is often required to monitor the progression of these injuries, as contusions can evolve and worsen over the first few days following the trauma.</li><li>• Statement 3: A single CT scan head is enough to assess overall extent of these injuries, no serial imaging required.</li><li>• false</li><li>• extent of cerebral contusions</li><li>• not be fully apparent on initial imaging</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Cerebral contusions are traumatic brain injuries most commonly affecting the frontal and temporal lobes . They can occur at the site of impact and also on the opposite side due to the movement of the brain within the skull during injury . Initial CT imaging may not show the full extent of the damage, and serial imaging is necessary to monitor the progression of cerebral contusions.</li><li>➤ Cerebral contusions</li><li>➤ traumatic brain injuries</li><li>➤ affecting the frontal and temporal lobes</li><li>➤ site of impact and also on the opposite side due to the movement of the brain within the skull during injury</li><li>➤ Coup counter-coup contusions refer to brain injury both at site of impact and distant to this , where the brain impacts on the inside of the skull as the skull and brain accelerate and then decelerate out of synchrony with each other. In a period of hours or days, contusions can evolve to form an intracerebral hematoma or a coalescent contusion with enough mass effect to require immediate surgical evacuation. This condition occurs in as many as 20% of patients presenting with contusions on initial CT scan of the head. For this reason, patients with contusions generally undergo repeat CT scanning to evaluate for changes in the pattern of injury within 24 hours of the initial scan.</li><li>➤ Coup counter-coup contusions refer to brain injury both at site of impact and distant to this , where the brain impacts on the inside of the skull as the skull and brain accelerate and then decelerate out of synchrony with each other.</li><li>➤ Coup counter-coup contusions</li><li>➤ brain injury both at site of impact and distant to this</li><li>➤ brain impacts on the inside of the skull as the skull and brain accelerate</li><li>➤ decelerate out of synchrony</li><li>➤ In a period of hours or days, contusions can evolve to form an intracerebral hematoma or a coalescent contusion with enough mass effect to require immediate surgical evacuation. This condition occurs in as many as 20% of patients presenting with contusions on initial CT scan of the head. For this reason, patients with contusions generally undergo repeat CT scanning to evaluate for changes in the pattern of injury within 24 hours of the initial scan.</li><li>➤ Ref : ATLS Student Manual 10th Edition Page 111</li><li>➤ Ref</li><li>➤ : ATLS Student Manual 10th Edition Page 111</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 367</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 367</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient of head injury due to an RTA was noted to have right sided hemiparesis and left sided pupillary dilatation. What is this classically seen with?", "options": [{"label": "A", "text": "Right sided injury causing uncal herniation", "correct": false}, {"label": "B", "text": "Left sided injury causing uncal herniation", "correct": true}, {"label": "C", "text": "Diffuse axonal injury", "correct": false}, {"label": "D", "text": "Concussion", "correct": false}], "correct_answer": "B. Left sided injury causing uncal herniation", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/picture13_f4jTF74.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/picture14_9X9VuXi.jpg"], "explanation": "<p><strong>Ans. B) Left sided injury causing uncal herniation</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Right sided injury causing uncal herniation This would typically cause ipsilateral (same side) pupillary dilation due to compression of the third cranial nerve and contralateral (opposite side) hemiparesis due to pressure on the cerebral peduncle. However, this does not match the patient's presentation.</li><li>• Option A: Right sided injury causing uncal herniation</li><li>• cause ipsilateral</li><li>• pupillary dilation</li><li>• compression of the third cranial nerve</li><li>• contralateral</li><li>• hemiparesis</li><li>• pressure on the cerebral peduncle.</li><li>• Option C: Diffuse axonal injury Diffuse axonal injury typically does not cause focal neurological signs such as unilateral pupillary dilation or hemiparesis . It is associated with widespread brain damage and is not consistent with the patient's presentation.</li><li>• Option C: Diffuse axonal injury</li><li>• not cause focal neurological signs</li><li>• unilateral pupillary dilation or hemiparesis</li><li>• Option D: Concussion might present with confusion, amnesia, or other diffuse symptoms but would not typically result in unilateral pupillary dilation and hemiparesis. These findings suggest a more focal injury than what is usually seen with a concussion.</li><li>• Option D: Concussion</li><li>• confusion, amnesia, or other diffuse symptoms</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In cases of head injury with clinical signs of ipsilateral pupillary dilation and contralateral hemiparesis , the likely diagnosis is uncal herniation on the side of the dilated pupil , indicating a true localizing sign of a focal brain injury . This condition requires prompt recognition and management to prevent further neurological deterioration.</li><li>➤ head injury with clinical signs of ipsilateral pupillary dilation</li><li>➤ contralateral hemiparesis</li><li>➤ diagnosis is uncal herniation on the side of the dilated pupil</li><li>➤ true localizing sign of a focal brain injury</li><li>➤ Uncal herniation can compress the third nerve, compromising the parasympathetic supply to the pupil. Unopposed sympathetic activity produces a sluggish enlarged pupil, progressing to fixed and dilated under continued compression. This is known as Hutchinson’s pupil and localizes the site of injury (true localizing sign). Ipsilateral pupillary dilatation and contralateral hemiparesis is the classic sign of uncal herniation. Rarely, the mass lesion pushes the opposite side of the midbrain against the tentorial edge, resulting in hemiparesis on the same side as the hematoma. This is called the Kernohan notch phenomenon and it is a false localizing sign.</li><li>➤ Uncal herniation can compress the third nerve, compromising the parasympathetic supply to the pupil. Unopposed sympathetic activity produces a sluggish enlarged pupil, progressing to fixed and dilated under continued compression. This is known as Hutchinson’s pupil and localizes the site of injury (true localizing sign).</li><li>➤ Uncal herniation can compress the third nerve, compromising the parasympathetic supply to the pupil. Unopposed sympathetic activity produces a sluggish enlarged pupil, progressing to fixed and dilated under continued compression. This is known as Hutchinson’s pupil and localizes the site of injury (true localizing sign).</li><li>➤ Ipsilateral pupillary dilatation and contralateral hemiparesis is the classic sign of uncal herniation.</li><li>➤ Ipsilateral pupillary dilatation and contralateral hemiparesis is the classic sign of uncal herniation.</li><li>➤ Rarely, the mass lesion pushes the opposite side of the midbrain against the tentorial edge, resulting in hemiparesis on the same side as the hematoma. This is called the Kernohan notch phenomenon and it is a false localizing sign.</li><li>➤ Rarely, the mass lesion pushes the opposite side of the midbrain against the tentorial edge, resulting in hemiparesis on the same side as the hematoma. This is called the Kernohan notch phenomenon and it is a false localizing sign.</li><li>➤ the opposite side of the midbrain</li><li>➤ Fig: Lateral (Uncal) Herniation. A lesion of the middle meningeal artery secondary to a fracture of the temporal bone may cause temporal epidural hematoma. The uncus compresses the upper brain stemm, involving the reticular system (decreasing GCS), the oculomotor nerve (pupillary changes), and the corticospinal tract in the midbrain (contralateral hemisparesis).</li><li>➤ Fig:</li><li>➤ Fig: Unequal pupils: The left is greater than the right.</li><li>➤ Fig:</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 363</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 363</li><li>➤ ATLS Student Manual 10th Edition Page 107</li><li>➤ ATLS Student Manual 10th Edition Page 107</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of the following are indications of getting a CT scan brain done within 1 hour in head injury, according to the NICE (National Institute for Health, Care and Excellence) guidelines except:", "options": [{"label": "A", "text": "A patient with a GCS of 12/15", "correct": false}, {"label": "B", "text": "A patient with suspected depressed skull fracture", "correct": false}, {"label": "C", "text": "A patient with one episode of vomiting", "correct": true}, {"label": "D", "text": "A patient with one episode of post- traumatic seizure", "correct": false}], "correct_answer": "C. A patient with one episode of vomiting", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) A patient with one episode of vomiting</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: A patient with a GCS of 12/15 A Glasgow Coma Scale (GCS) score of less than 13 at any point post-injury is an indication for a CT scan within 1 hour according to NICE guidelines. This is because a score less than 13 suggests a significant alteration in consciousness, which could be due to a serious brain injury.</li><li>• Option A: A patient with a GCS of 12/15</li><li>• Glasgow Coma Scale</li><li>• score of less than 13 at any point post-injury is an indication for a CT scan within 1 hour</li><li>• Option B: A patient with suspected depressed skull fracture A suspected open, depressed, or basal skull fracture is an indication for an urgent CT scan . These types of fractures can be associated with underlying brain injury, dural tears, and risk of infection.</li><li>• Option B: A patient with suspected depressed skull fracture</li><li>• basal skull fracture</li><li>• urgent CT scan</li><li>• Option D: A patient with one episode of post-traumatic seizure A post-traumatic seizure is an indication for an urgent CT scan within 1 hour because it may signify a significant brain injury, such as an intracranial hemorrhage, which could require immediate intervention.</li><li>• Option D: A patient with one episode of post-traumatic seizure</li><li>• urgent CT scan within 1 hour</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ According to NICE guidelines , the indications for a CT scan within 1 hour of head injury include a GCS score of less than 13 at any point , a GCS score of less than 15 at 2 hours , any focal neurological deficit , suspected open or depressed skull fractures , more than one episode of vomiting, and any post-traumatic seizure. A single episode of vomiting is not an indication for a CT scan within 1 hour unless other risk factors are present.</li><li>➤ NICE guidelines</li><li>➤ CT scan within 1 hour of head injury</li><li>➤ GCS score of less than 13 at any point</li><li>➤ GCS score of less than 15 at 2 hours</li><li>➤ focal neurological deficit</li><li>➤ open or depressed skull fractures</li><li>➤ UK National Institute for Health and Care Excellence (NICE) guidelines for computed tomography (CT) in head injury-</li><li>➤ Indications for CT imaging in head injury within 1 hour</li><li>➤ GCS &lt;13 at any point GCS &lt;15 at 2 hours Focal neurological deficit Suspected open, depressed or basal skull fracture More than one episode of vomiting Post-traumatic seizure</li><li>➤ GCS &lt;13 at any point</li><li>➤ GCS &lt;15 at 2 hours</li><li>➤ Focal neurological deficit</li><li>➤ Suspected open, depressed or basal skull fracture</li><li>➤ More than one episode of vomiting</li><li>➤ Post-traumatic seizure</li><li>➤ Indications for CT imaging within 8 hours</li><li>➤ Indications for CT imaging within 8 hours</li><li>➤ Age &gt;65 Coagulopathy (e.g., aspirin, warfarin or rivaroxaban use) Dangerous mechanism of injury (e.g., fall from a height, RTA) Retrograde amnesia &gt;30 minutes</li><li>➤ Age &gt;65</li><li>➤ Coagulopathy (e.g., aspirin, warfarin or rivaroxaban use)</li><li>➤ Dangerous mechanism of injury (e.g., fall from a height, RTA)</li><li>➤ Retrograde amnesia &gt;30 minutes</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 362.</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 362.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient of mild head injury was observed for a few hours and then the decision for discharge had to be made. Which of the following would deter (stop) you from going ahead with the discharge formalities of this patient?", "options": [{"label": "A", "text": "GCS 15/15 with no neuro-deficit", "correct": false}, {"label": "B", "text": "Patient not under the influence of any drug or alcohol", "correct": false}, {"label": "C", "text": "Patient living alone", "correct": true}, {"label": "D", "text": "Proper verbal and written head injury advice explained and understood", "correct": false}], "correct_answer": "C. Patient living alone", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Patient alone, not accompanied by anyone</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: GCS 15/15 with no neurodeficit A Glasgow Coma Scale (GCS) score of 15/15 with no neurological deficits is an indicator that the patient's mental status is stable and not impaired, which typically supports the decision for discharge provided all other criteria are met.</li><li>• Option A: GCS 15/15 with no neurodeficit</li><li>• Glasgow Coma Scale</li><li>• score of 15/15 with no neurological deficits</li><li>• patient's mental status is stable</li><li>• Option B: Patient not under the influence of any drug or alcohol Not being under the influence of drugs or alcohol is important because these substances can mask or mimic the symptoms of a head injury . Since the patient is not under the influence, this would support safe discharge assuming other criteria are satisfied.</li><li>• Option B: Patient not under the influence of any drug or alcohol</li><li>• under the influence of drugs or alcohol is important</li><li>• substances can mask or mimic the symptoms of a head injury</li><li>• Option D: Proper verbal and written head injury advice explained and understood Providing the patient with proper verbal and written advice about what to do post-discharge and ensuring they understand this advice is critical for safe discharge. This includes instructions on what symptoms to look out for that would necessitate a return to the hospital.</li><li>• Option D: Proper verbal and written head injury advice explained and understood</li><li>• patient with proper verbal and written advice</li><li>• what to do post-discharge</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ When considering discharge for a patient with a mild head injury , it's important to ensure that they have a normal GCS score , are not under the influence of substances , have understood discharge advice, and are accompanied by a responsible adult who can monitor them for any emerging symptoms that require medical attention. Discharging a patient who is alone is not recommended as it could lead to an unsafe situation if the patient's condition worsens post-discharge.</li><li>➤ discharge for a patient with a mild head injury</li><li>➤ normal GCS score</li><li>➤ not under the influence of substances</li><li>➤ UK National Institute for Health and Care Excellence discharge criteria in minor and mild head injury -</li><li>➤ UK National Institute</li><li>➤ Health and Care Excellence discharge</li><li>➤ minor and mild head injury</li><li>➤ GCS 15/15 with no focal deficits Normal CT brain if indicated Patient not under the influence of alcohol or drugs Patient accompanied by a responsible adult Verbal and written head injury advice: seek medical attention if: Persistent/worsening headache despite analgesia Persistent vomiting Drowsiness Visual disturbance Limb weakness or numbness</li><li>➤ GCS 15/15 with no focal deficits</li><li>➤ Normal CT brain if indicated</li><li>➤ Patient not under the influence of alcohol or drugs</li><li>➤ Patient accompanied by a responsible adult</li><li>➤ Verbal and written head injury advice: seek medical attention if: Persistent/worsening headache despite analgesia Persistent vomiting Drowsiness Visual disturbance Limb weakness or numbness</li><li>➤ Persistent/worsening headache despite analgesia Persistent vomiting Drowsiness Visual disturbance Limb weakness or numbness</li><li>➤ Persistent/worsening headache despite analgesia</li><li>➤ Persistent vomiting</li><li>➤ Drowsiness</li><li>➤ Visual disturbance</li><li>➤ Limb weakness or numbness</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 362.</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 362.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "The sign shown below is seen in.", "options": [{"label": "A", "text": "Middle cranial fossa fracture", "correct": true}, {"label": "B", "text": "Anterior cranial fossa fracture", "correct": false}, {"label": "C", "text": "Zygomatic fracture", "correct": false}, {"label": "D", "text": "Mandibular fracture", "correct": false}], "correct_answer": "A. Middle cranial fossa fracture", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture15.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture16.jpg"], "explanation": "<p><strong>Ans. A) Middle cranial fossa fracture</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the true statement:", "options": [{"label": "A", "text": "Closed linear fractures of the skull vault should never be managed conservatively", "correct": false}, {"label": "B", "text": "Comminuted or open fractures do not need debridement or prophylactic antibiotics", "correct": false}, {"label": "C", "text": "A depressed skull fracture of inward displacement less than the skull thickness requires operative interference", "correct": false}, {"label": "D", "text": "Fractures involving air sinuses should be generally managed as open fractures", "correct": true}], "correct_answer": "D. Fractures involving air sinuses should be generally managed as open fractures", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D. Fractures involving air sinuses should be generally managed as open fractures</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Closed linear fractures of the skull vault are generally managed conservatively.</li><li>• Option A:</li><li>• generally managed conservatively.</li><li>• Option B: Comminuted or open fractures should be considered for debridement and prophylactic antibiotics .</li><li>• Option B:</li><li>• considered for debridement and prophylactic antibiotics</li><li>• Option C: Generally, depressed skull fractures require operative elevation when the degree of depression is greater than the thickness of the adjacent skull , or when they are open and grossly contaminated . Less severe depressed fractures can often be managed with closure of the overlying scalp laceration, if present.</li><li>• Option C:</li><li>• depressed skull fractures</li><li>• operative elevation</li><li>• degree of depression is greater than the thickness of the adjacent skull</li><li>• open and grossly contaminated</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Fractures involving air sinuses should be generally managed as open fractures with broad-spectrum antibiotics with or without exploration.</li><li>• Fractures involving air sinuses</li><li>• managed as open fractures with broad-spectrum antibiotics</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 364</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Page 364</li><li>• ATLS Student Manual 10th Edition Page 123</li><li>• ATLS Student Manual 10th Edition Page 123</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the type of Le-Fort fracture in the image below.", "options": [{"label": "A", "text": "Le-Fort fracture type I", "correct": false}, {"label": "B", "text": "Le-Fort fracture type II", "correct": true}, {"label": "C", "text": "Le-Fort fracture type III", "correct": false}, {"label": "D", "text": "Linear fracture of skull base", "correct": false}], "correct_answer": "B. Le-Fort fracture type II", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture1.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture2.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture3.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture4.jpg"], "explanation": "<p><strong>Ans. B) Le-Fort fracture type II</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Le-Fort fractures-</li><li>• Type I - Horizontal fracture line passing through lower part of nasal septum , maxillary antra and pterygoid plates .</li><li>• Type I</li><li>• Horizontal fracture line</li><li>• lower part of nasal septum</li><li>• maxillary antra</li><li>• pterygoid plates</li><li>• Floating teeth / palate Guerin’s fracture</li><li>• Floating teeth / palate</li><li>• Guerin’s fracture</li><li>• Type II - pyramidal fracture</li><li>• Type II</li><li>• pyramidal fracture</li><li>• Fracture line through root of nose, lacrimal bone, floor of orbit, upper part of maxillary sinus and pterygoid plates . Hanging maxilla CSF rhinorrhea</li><li>• Fracture line through root of nose, lacrimal bone, floor of orbit, upper part of maxillary sinus and pterygoid plates .</li><li>• Fracture line</li><li>• root of nose, lacrimal bone, floor of orbit, upper part of maxillary sinus</li><li>• pterygoid plates</li><li>• Hanging maxilla</li><li>• CSF rhinorrhea</li><li>• Type III - craniofacial dysjunction ie. facial skeleton completely disconnected from its cranial attachment.</li><li>• Type III</li><li>• craniofacial dysjunction</li><li>• Fracture line through root of nose, ethmo-frontal junction, superior orbital fissure, lateral wall of orbit, front-zygomatic sutures and upper part of pterygoid plates . CSF rhinorrhea</li><li>• Fracture line through root of nose, ethmo-frontal junction, superior orbital fissure, lateral wall of orbit, front-zygomatic sutures and upper part of pterygoid plates .</li><li>• Fracture line</li><li>• root of nose, ethmo-frontal junction, superior orbital fissure, lateral wall of orbit, front-zygomatic sutures and upper part of pterygoid plates</li><li>• CSF rhinorrhea</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• The Le Fort classification system is used to describe fractures of the midface , which are complex and often involve the maxillary bone and surrounding structures . There are three types of Le Fort fractures .</li><li>• Le Fort classification system</li><li>• fractures of the midface</li><li>• which are complex</li><li>• often involve the maxillary bone</li><li>• surrounding structures</li><li>• three types of Le Fort fractures</li><li>• Ref : Bailey and Love 28 th Ed. Pg 412.</li><li>• Ref</li><li>• : Bailey and Love 28 th Ed. Pg 412.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Arrange the layers of scalp in correct order from outside to inside: Connective tissue Periosteum Loose areolar tissue Aponeurosis", "options": [{"label": "A", "text": "a, b, c, d", "correct": false}, {"label": "B", "text": "a, d, c, b", "correct": true}, {"label": "C", "text": "a, c, b, d", "correct": false}, {"label": "D", "text": "a, c, d, b", "correct": false}], "correct_answer": "B. a, d, c, b", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture5.jpg"], "explanation": "<p><strong>Ans. B) a,</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Layers of scalp from outside to inside -</li><li>• Layers of scalp from outside to inside</li><li>• Skin Connective tissue Aponeurosis Loose areolar tissue Periosteum</li><li>• Skin</li><li>• Connective tissue</li><li>• Aponeurosis</li><li>• Loose areolar tissue</li><li>• Periosteum</li><li>• Scalp lacerations usually bleed a lot because blood vessels retract into loose areolar tissue so bleeding is not easily arrested . The loose areolar layer is sometimes referred to as the \"danger zone\" because of the ease by which infectious agents can spread through it via the emissary veins which then drain into the cranium .</li><li>• Scalp lacerations</li><li>• bleed a lot because blood vessels retract into loose areolar tissue</li><li>• bleeding is not easily arrested</li><li>• loose areolar layer</li><li>• \"danger zone\"</li><li>• ease by which infectious agents can spread through it via the emissary veins</li><li>• drain into the cranium</li><li>• Scalp lacerations through the aponeurosis mean that the \"anchoring\" of the superficial layers is lost and gaping of the wound occurs which would require suturing.</li><li>• Scalp lacerations</li><li>• aponeurosis</li><li>• \"anchoring\" of the superficial layers</li><li>• lost and gaping</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Layers of scalp from outside to inside are-</li><li>• Layers of scalp from outside to inside</li><li>• Skin Connective tissue Aponeurosis Loose areolar tissue Periosteum</li><li>• Skin</li><li>• Connective tissue</li><li>• Aponeurosis</li><li>• Loose areolar tissue</li><li>• Periosteum</li><li>• Ref : BD Chaurasia’s Human Anatomy 8 th Ed., Volume 2, Pg 63-64.</li><li>• Ref</li><li>• : BD Chaurasia’s Human Anatomy 8 th Ed., Volume 2, Pg 63-64.</li><li>• https://www.ncbi.nlm.nih.gov/books/NBK551565/</li><li>• https://www.ncbi.nlm.nih.gov/books/NBK551565/</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is not recommended according to the ATLS guidelines, in the medical management of head injury patients?", "options": [{"label": "A", "text": "Routine use of steroids", "correct": true}, {"label": "B", "text": "Mannitol", "correct": false}, {"label": "C", "text": "Reverse Trendelenberg position", "correct": false}, {"label": "D", "text": "Serum sodium levels monitoring", "correct": false}], "correct_answer": "A. Routine use of steroids", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Routine use of steroids</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Mannitol Mannitol is an osmotic diuretic used to reduce intracranial pressure (ICP). It is indicated in cases of elevated ICP in head injury patients . Mannitol works by drawing fluid out of the brain tissue and into the blood vessels, thus reducing ICP.</li><li>• Option B: Mannitol</li><li>• osmotic diuretic used to reduce intracranial pressure</li><li>• indicated in cases of elevated ICP</li><li>• head injury patients</li><li>• Option C: Reverse Trendelenberg position The Reverse Trendelenberg position, where the patient is tilted so that the head is higher than the feet , can be used to help reduce ICP by promoting venous drainage from the brain . However, it must be used cautiously and in the appropriate clinical setting to avoid complications such as reduced cerebral perfusion.</li><li>• Option C: Reverse Trendelenberg position</li><li>• patient is tilted so that the head is higher than the feet</li><li>• used to help reduce ICP by promoting venous drainage from the brain</li><li>• Option D: Serum sodium levels monitoring Monitoring serum sodium levels is important in the management of head injury patients . Hyponatremia (low sodium level) can lead to cerebral edema and worsen brain injury , while hypernatremia (high sodium level) can cause dehydration and shrinkage of brain cells , potentially leading to intracranial bleeding.</li><li>• Option D: Serum sodium levels monitoring</li><li>• management of head injury patients</li><li>• Hyponatremia</li><li>• lead to cerebral edema and worsen brain injury</li><li>• hypernatremia</li><li>• dehydration and shrinkage of brain cells</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In the management of head injury patients , the ATLS guidelines recommend against the routine use of steroids due to associated increased mortality and lack of benefit . Instead, management strategies focus on preventing secondary brain injury by controlling ICP and monitoring vital parameters such as serum sodium levels . Mannitol may be used for reducing ICP, and patient positioning should be optimized to support venous drainage and reduce intracranial pressure.</li><li>➤ management of head injury patients</li><li>➤ ATLS guidelines</li><li>➤ against the routine use of steroids</li><li>➤ associated increased mortality and lack of benefit</li><li>➤ management strategies focus on preventing secondary brain injury</li><li>➤ controlling ICP and monitoring vital parameters</li><li>➤ serum sodium levels</li><li>➤ Medical management strategies aim to minimise secondary brain injury through avoidance of hypoxia and hypotension and control of ICP. Unchecked, secondary injury leads to a further cycle of deterioration . Brain swelling and mass lesions contribute to raised intracranial pressure, which compromises perfusion, leading to secondary brain injury and further swelling. ICP can be controlled by simple measures, including raising the head of the bed and loosening the collar to improve venous drainage. Seizures and pyrexia should be actively controlled. Medical management titrated to ICP includes escalating doses of sedatives, analgesics and ultimately muscle relaxants. Where these measures fail, control brain swelling using mannitol or hypertonic saline infusions. Carefully monitor serum sodium levels in patients with head injuries. Hyponatremia is associated with brain edema and should be prevented.</li><li>➤ Medical management strategies aim to minimise secondary brain injury through avoidance of hypoxia and hypotension and control of ICP. Unchecked, secondary injury leads to a further cycle of deterioration . Brain swelling and mass lesions contribute to raised intracranial pressure, which compromises perfusion, leading to secondary brain injury and further swelling.</li><li>➤ ICP can be controlled by simple measures, including raising the head of the bed and loosening the collar to improve venous drainage. Seizures and pyrexia should be actively controlled.</li><li>➤ Medical management titrated to ICP includes escalating doses of sedatives, analgesics and ultimately muscle relaxants. Where these measures fail, control brain swelling using mannitol or hypertonic saline infusions.</li><li>➤ Carefully monitor serum sodium levels in patients with head injuries. Hyponatremia is associated with brain edema and should be prevented.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 368.</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 368.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Read the following statements and choose true or false: Continuous and prophylactic hyperventilation is recommended in patients with raised ICP due to head injury. Prophylactic anti-epileptics are recommended to prevent late onset post traumatic seizures.", "options": [{"label": "A", "text": "T T", "correct": false}, {"label": "B", "text": "F T", "correct": false}, {"label": "C", "text": "T F", "correct": false}, {"label": "D", "text": "F F", "correct": true}], "correct_answer": "D. F F", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) F F</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Statement A: Continuous and prophylactic hyperventilation is recommended in patients with raised ICP due to head injury. False.</li><li>• Statement A:</li><li>• Continuous and prophylactic hyperventilation is recommended in patients with raised ICP due to head injury.</li><li>• Continuous or prophylactic hyperventilation is not recommended for patients with raised intracranial pressure (ICP) due to head injury as a routine measure . While hyperventilation can lead to a rapid but temporary reduction in ICP by causing vasoconstriction and reducing cerebral blood flow, it can also potentially decrease oxygen delivery to the brain and lead to ischemia. Hyperventilation is typically reserved for acute worsening of neurological status or other signs of impending herniation as a temporizing measure until definitive treatment can be provided.</li><li>• Continuous or prophylactic hyperventilation</li><li>• not recommended for patients with raised intracranial pressure</li><li>• head injury as a routine measure</li><li>• Statement B: Prophylactic anti-epileptics are recommended to prevent late onset post traumatic seizures. False.</li><li>• Statement B:</li><li>• Prophylactic anti-epileptics are recommended to prevent late onset post traumatic seizures.</li><li>• Prophylactic anti-epileptics may be used in the early period following a traumatic brain injury to prevent early post-traumatic seizures , but they are not recommended routinely to prevent late post-traumatic seizures. The use of anti-epileptic drugs for the prevention of late seizures (occurring more than 7 days after injury) is not supported by evidence and is not recommended due to the potential side effects of these medications and the lack of efficacy shown in preventing late seizures.</li><li>• Prophylactic anti-epileptics</li><li>• early period following a traumatic brain injury to prevent early post-traumatic seizures</li><li>• not recommended routinely to prevent late post-traumatic seizures.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In the management of head injury , continuous or prophylactic hyperventilation is not recommended due to the risk of cerebral ischemia . Prophylactic anti-epileptics are not recommended for the prevention of late post-traumatic seizures due to the lack of evidence for efficacy and potential medication side effects.</li><li>➤ management of head injury</li><li>➤ continuous or prophylactic hyperventilation</li><li>➤ not recommended due to the risk of cerebral ischemia</li><li>➤ Prophylactic hyperventilation (pCO2 &lt; 25 mm Hg) is not recommended (IIB): Hyperventilation only in moderation and for as limited a period as possible. Aggressive and prolonged hyperventilation can result in cerebral ischemia in the already injured brain by causing severe cerebral vasoconstriction and thus impaired cerebral perfusion. Prophylactic use of phenytoin or valproate is not recommended for preventing late post-traumatic seizures (PTS). Phenytoin is recommended to decrease the incidence of early PTS (within 7 days of injury).</li><li>➤ Prophylactic hyperventilation (pCO2 &lt; 25 mm Hg) is not recommended (IIB): Hyperventilation only in moderation and for as limited a period as possible. Aggressive and prolonged hyperventilation can result in cerebral ischemia in the already injured brain by causing severe cerebral vasoconstriction and thus impaired cerebral perfusion.</li><li>➤ Prophylactic hyperventilation</li><li>➤ not recommended</li><li>➤ Prophylactic use of phenytoin or valproate is not recommended for preventing late post-traumatic seizures (PTS). Phenytoin is recommended to decrease the incidence of early PTS (within 7 days of injury).</li><li>➤ Prophylactic use of phenytoin or valproate is not recommended for preventing</li><li>➤ late</li><li>➤ post-traumatic seizures</li><li>➤ Ref : ATLS Student Manual 10th Edition Page 121-122</li><li>➤ Ref</li><li>➤ : ATLS Student Manual 10th Edition Page 121-122</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "About neck trauma, choose the correct statement:", "options": [{"label": "A", "text": "First step in evaluation of an unstable patient with neck trauma is CT angiography", "correct": false}, {"label": "B", "text": "Zone 1 is the most commonly involved zone", "correct": false}, {"label": "C", "text": "All patients with Zone 2 injury require operative intervention", "correct": false}, {"label": "D", "text": "Zone 3 extends between angle of mandible and base of skull", "correct": true}], "correct_answer": "D. Zone 3 extends between angle of mandible and base of skull", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture6.jpg"], "explanation": "<p><strong>Ans. D) Zone 3 extends between angle of mandible and base of skull</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: First step in evaluation of an unstable patient with neck trauma is CT angiography This is incorrect . The first step in the evaluation of an unstable patient with neck trauma is not CT angiography but rather immediate resuscitation and stabilization according to Advanced Trauma Life Support (ATLS) guidelines . CT angiography is a diagnostic tool used after the patient is hemodynamically stable.</li><li>• Option A: First step in evaluation of an unstable patient with neck trauma is CT angiography</li><li>• incorrect</li><li>• first step in the evaluation of an unstable patient with neck trauma</li><li>• not CT angiography</li><li>• rather immediate resuscitation and stabilization according to Advanced Trauma Life Support</li><li>• guidelines</li><li>• Option B: Zone 1 is the most commonly involved zone This is incorrect . Zone 1 is not the most commonly involved zone in neck trauma, it is Zone 2.</li><li>• Option B: Zone 1 is the most commonly involved zone</li><li>• incorrect</li><li>• Zone 1 is not the most commonly involved zone</li><li>• Option C: All patients with Zone 2 injury require operative intervention This is incorrect . Not all Zone 2 injuries require operative intervention . Zone 2 , which stretches from the cricoid cartilage to the angle of the mandible , is the most surgically accessible . However, surgery is only required if there is evidence of active bleeding, expanding hematoma, or an obvious aerodigestive tract injury.</li><li>• Option C: All patients with Zone 2 injury require operative intervention</li><li>• incorrect</li><li>• Zone 2 injuries require operative intervention</li><li>• Zone 2</li><li>• stretches from the cricoid cartilage to the angle of the mandible</li><li>• most surgically accessible</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The correct management of neck trauma involves understanding the anatomical zones of the neck . Zone 1 extends from the thoracic inlet to the cricoid cartilage , Zone 2 from the cricoid cartilage to the angle of the mandible , and Zone 3 from the angle of the mandible to the base of the skull. Immediate surgical intervention in neck trauma is not always required and depends on the zone of injury, the stability of the patient, and the presence of active bleeding or aerodigestive injury.</li><li>➤ correct management of neck trauma</li><li>➤ understanding the anatomical zones of the neck</li><li>➤ Zone 1 extends from the thoracic inlet to the cricoid cartilage</li><li>➤ Zone 2</li><li>➤ cricoid cartilage to the angle of the mandible</li><li>➤ Zone 3</li><li>➤ angle of the mandible to the base of the skull.</li><li>➤ Unstable patients should be taken immediately to the operating room, and the structures of the neck will be evaluated with direct visualization. Stable patients require further evaluation for neck injury with physical examination and imaging.</li><li>➤ Unstable patients should be taken immediately to the operating room, and the structures of the neck will be evaluated with direct visualization. Stable patients require further evaluation for neck injury with physical examination and imaging.</li><li>➤ Zone I extends from the thoracic inlet to the cricoid cartilage and contains large vascular structures as well as the trachea and esophagus.</li><li>➤ Zone I extends from the thoracic inlet to the cricoid cartilage</li><li>➤ large vascular structures</li><li>➤ Zone II stretches from the cricoid cartilage to the angle of the mandible , is the most accessible surgically and contains the carotid and vertebral arteries, jugular veins and structures of the aerodigestive tract. In Zone II injury, only patients with evidence of active bleeding or an obvious aerodigestive injury require surgery.</li><li>➤ Zone II stretches from the cricoid cartilage</li><li>➤ to the angle of the mandible</li><li>➤ Zone III includes the neck between the angle of the mandible and the base of the skull . Structures within zone III include blood vessels that are difficult to expose surgically.</li><li>➤ Zone III includes the</li><li>➤ neck between the angle of the mandible and the base of the skull</li><li>➤ Fig: Zones of the Neck. Zone 1 extends from the thoracic inlet to the cricoid cartilage. Zone 2 is between the cricoid cartilage and the angle of the mandible. Zone 3 extends from the angle of the</li><li>➤ Fig:</li><li>➤ mandible to the skull base.</li><li>➤ Regardless of anatomic location, stable neck injuries can be evaluated with selective diagnostic</li><li>➤ studies.</li><li>➤ IOC - CT scan neck</li><li>➤ Ref : Sabiston Textbook of Surgery 20th Edition Page 423-425</li><li>➤ Ref</li><li>➤ : Sabiston Textbook of Surgery 20th Edition Page 423-425</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A victim of robbery and violence was brought to the casualty with multiple lacerations on the neck. Which of the following is an indication for immediate surgical exploration in this patient?", "options": [{"label": "A", "text": "Expanding neck hematoma", "correct": false}, {"label": "B", "text": "Air bubbling from the penetrating injury", "correct": false}, {"label": "C", "text": "Focal neurological deficit", "correct": false}, {"label": "D", "text": "All of the above", "correct": true}], "correct_answer": "D. All of the above", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) All of the above</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Expanding neck hematoma an expanding neck hematoma is a sign of ongoing bleeding and is a critical indication for immediate surgical exploration. It can signify vascular injury that may lead to airway compromise or further hemorrhage if not promptly managed.</li><li>• Option A: Expanding neck hematoma</li><li>• sign of ongoing bleeding and is a critical indication for immediate surgical exploration.</li><li>• Option B: Air bubbling from the penetrating injury Air bubbling from a penetrating neck injury is indicative of an open communication with the trachea . This is a surgical emergency as it suggests a significant risk of air embolism, ongoing blood loss, or the development of a tension pneumothorax.</li><li>• Option B: Air bubbling from the penetrating injury</li><li>• indicative of an open communication with the trachea</li><li>• Option C: Focal neurological deficit A focal neurological deficit following neck trauma could indicate injury to the spinal cord or vascular injury leading to stroke . This requires urgent surgical assessment to determine the cause and appropriate intervention to prevent further neurological damage.</li><li>• Option C: Focal neurological deficit</li><li>• neck trauma could indicate injury to the spinal cord or vascular injury leading to stroke</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The presence of an expanding neck hematoma , air bubbling from a penetrating injury , or a focal neurological deficit are all hard signs of significant neck trauma . These findings necessitate immediate surgical exploration to identify and control the source of bleeding, to repair structural damage, and to prevent further morbidity or mortality.</li><li>➤ presence of an expanding neck hematoma</li><li>➤ air bubbling from a penetrating injury</li><li>➤ focal neurological deficit are all hard signs of significant neck trauma</li><li>➤ Hard signs of neck trauma, which require immediate surgical exploration are-</li><li>➤ Expanding neck hematoma / pulsation bleeding Air bubbling from penetrating trauma Arterial hemorrhage from neck, nose, or mouth Focal neurologic deficit Cervical bruit (patient &lt; 50 years old) Stroke on CT or MRI Neurologic deficit unexplained by CT findings</li><li>➤ Expanding neck hematoma / pulsation bleeding</li><li>➤ Air bubbling from penetrating trauma</li><li>➤ Arterial hemorrhage from neck, nose, or mouth</li><li>➤ Focal neurologic deficit</li><li>➤ Cervical bruit (patient &lt; 50 years old)</li><li>➤ Stroke on CT or MRI</li><li>➤ Neurologic deficit unexplained by CT findings</li><li>➤ Ref : Sabiston Textbook of Surgery 20th Edition Page 423-425</li><li>➤ Ref : Sabiston Textbook of Surgery 20th Edition Page 423-425</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is not immediately life threatening, according to the Deadly Dozen of Chest Trauma?", "options": [{"label": "A", "text": "Myocardial contusion", "correct": true}, {"label": "B", "text": "Tension pneumothorax", "correct": false}, {"label": "C", "text": "Open pneumothorax", "correct": false}, {"label": "D", "text": "Airway obstruction", "correct": false}], "correct_answer": "A. Myocardial contusion", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-100821.jpg"], "explanation": "<p><strong>Ans. A) Myocardial contusion</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Myocardial contusion is not considered an immediately life-threatening condition .</li><li>• Myocardial contusion</li><li>• not considered an immediately life-threatening condition</li><li>• Ref : ATLS Student Manual - 10th Edition Page 64</li><li>• Ref</li><li>• : ATLS Student Manual - 10th Edition Page 64</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 30-year-old male patient of RTA was rushed into the casualty with complaints of dyspnea. His GCS was 15/15, BP=86/60 mm Hg, Pulse=110/min. JVP is also elevated. On systemic examination, the left side of the chest is hyper-resonant on percussion, with decreased breath sounds. Right side appears normal. Abdomen is soft and non-tender on palpation. What is the most probable diagnosis?", "options": [{"label": "A", "text": "Cardiac tamponade", "correct": false}, {"label": "B", "text": "Tension pneumothorax", "correct": true}, {"label": "C", "text": "Hemothorax", "correct": false}, {"label": "D", "text": "Pleural effusion", "correct": false}], "correct_answer": "B. Tension pneumothorax", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture7.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture8.jpg"], "explanation": "<p><strong>Ans. B) Tension pneumothorax</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Cardiac tamponade Cardiac tamponade is characterized by compression of the heart due to fluid accumulation in the pericardial sac . While it can lead to hemodynamic compromise similar to tension pneumothorax, it typically presents with muffled heart sounds, distant heart sounds, and pulsus paradoxus. The presence hyper-resonant percussion and decreased breath sounds on one side of the chest suggests a thoracic rather than cardiac pathology.</li><li>• Option A: Cardiac tamponade</li><li>• compression of the heart due to fluid accumulation in the pericardial sac</li><li>• Option C: Hemothorax Hemothorax refers to blood accumulation in the pleural cavity and can present with symptoms similar to tension pneumothorax such as dyspnea and decreased breath sounds . However, the neck veins should be collapsed and percussion should yield a dull note.</li><li>• Option C: Hemothorax</li><li>• blood accumulation in the pleural cavity and can present with symptoms similar to tension pneumothorax such as dyspnea</li><li>• decreased breath sounds</li><li>• Option D: Pleural effusion Pleural effusion is the accumulation of fluid in the pleural space . It can cause dyspnea and decreased breath sounds, but it typically presents with dullness to percussion rather than the hyper-resonance seen in tension pneumothorax.</li><li>• Option D: Pleural effusion</li><li>• accumulation of fluid in the pleural space</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Signs and symptoms of tension pneumothorax include acute dyspnea, chest pain, hemodynamic instability, distended neck veins, tracheal deviation , and decreased breath sounds on the affected side .</li><li>➤ Signs and symptoms of tension pneumothorax</li><li>➤ acute dyspnea, chest pain, hemodynamic instability, distended neck veins, tracheal deviation</li><li>➤ decreased breath sounds</li><li>➤ affected side</li><li>➤ Signs of tension pneumothorax-</li><li>➤ Signs of tension pneumothorax-</li><li>➤ Sudden onset hemodynamic compromise with hypotension, tachycardia, decreased SpO2 Distended neck veins Tracheal deviation to opposite side Decreased chest movements and breath sounds on affected side Hyper-resonance on percussion of affected side</li><li>➤ Sudden onset hemodynamic compromise with hypotension, tachycardia, decreased SpO2</li><li>➤ Distended neck veins</li><li>➤ Tracheal deviation to opposite side</li><li>➤ Decreased chest movements and breath sounds on affected side</li><li>➤ Hyper-resonance on percussion of affected side</li><li>➤ Fig: Tension Pneumothorax. A “one-way valve” air leak occurs from the lung or through the chest wall, and air is forced into the thoracic cavity, eventually collapsing the affected lung.</li><li>➤ Fig:</li><li>➤ It is a clinical diagnosis; treatment should never be delayed while waiting for radiological confirmation.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 374</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 374</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old male patient, brought into the casualty with features of tension pneumothorax due to trauma, needs to be managed. What is your next best step in management?", "options": [{"label": "A", "text": "Urgent chest X-ray PA view to confirm diagnosis", "correct": false}, {"label": "B", "text": "Wide bore needle insertion in 5th intercostal space mid clavicular line", "correct": false}, {"label": "C", "text": "Wide bore needle insertion in 5th intercostal space mid axillary line", "correct": true}, {"label": "D", "text": "Wide bore needle insertion in 2nd intercostal space mid clavicular line.", "correct": false}], "correct_answer": "C. Wide bore needle insertion in 5th intercostal space mid axillary line", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Wide bore needle insertion in 5th intercostal space mid axillary line.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Urgent chest x-ray PA view to confirm diagnosis This is not the next best step in management. While a chest x-ray is helpful for confirming the diagnosis of tension pneumothorax and assessing the extent of lung collapse , it should not delay emergent intervention . Tension pneumothorax is a clinical diagnosis, and immediate treatment is necessary to prevent further deterioration.</li><li>• Option A: Urgent chest x-ray PA view to confirm diagnosis</li><li>• not the next best step in management.</li><li>• chest x-ray is helpful for confirming the diagnosis of tension pneumothorax</li><li>• assessing the extent of lung collapse</li><li>• not delay emergent intervention</li><li>• Option B: Wide bore needle insertion in 5th intercostal space mid clavicular line This is incorrect . Insertion at the 5th intercostal space mid clavicular line may risk injury to underlying structures such as the heart.</li><li>• Option B: Wide bore needle insertion in 5th intercostal space mid clavicular line</li><li>• incorrect</li><li>• structures such as the heart.</li><li>• Option D: Wide bore needle insertion in 2nd intercostal space mid clavicular line This is incorrect . This is the site for needle insertion in children , not adults.</li><li>• Option D: Wide bore needle insertion in 2nd intercostal space mid clavicular line</li><li>• incorrect</li><li>• insertion in children</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The next best step in management is immediate needle decompression in the triangle of safety , specifically in the 5th intercostal space mid-axillary line , to rapidly relieve the pressure and stabilize the patient's condition.</li><li>➤ next best step</li><li>➤ management is immediate needle decompression in the triangle of safety</li><li>➤ 5th intercostal space mid-axillary line</li><li>➤ rapidly relieve the pressure and stabilize the patient's condition.</li><li>➤ Management- immediate needle decompression in the triangle of safety (5th intercostal space), the boundaries of which are:</li><li>➤ Posteriorly- latissimus dorsi Anteriorly- lateral border of pectoralis major Inferiorly- 5th intercostal space Located just anterior to mid-axillary line</li><li>➤ Posteriorly- latissimus dorsi</li><li>➤ Anteriorly- lateral border of pectoralis major</li><li>➤ Inferiorly- 5th intercostal space</li><li>➤ Located just anterior to mid-axillary line</li><li>➤ In extreme cases, a finger thoracostomy at the same location.</li><li>➤ In pediatric cases, needle decompression in the 2nd ICS midclavicular line.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 374</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 374</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient with a stab injury to the chest was brought into the ER. On examination, his BP was 86/60 mm Hg, neck veins were distended. On chest examination, breath sounds were present and equal bilaterally. Heart sounds on auscultation were however muffled. What is the likely diagnosis?", "options": [{"label": "A", "text": "Tension pneumothorax", "correct": false}, {"label": "B", "text": "Simple pneumothorax", "correct": false}, {"label": "C", "text": "Pericardial tamponade", "correct": true}, {"label": "D", "text": "Massive hemothorax", "correct": false}], "correct_answer": "C. Pericardial tamponade", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture14.jpg"], "explanation": "<p><strong>Ans. C) Pericardial tamponade</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Tension pneumothorax - This condition occurs when air enters the pleural space and cannot escape, leading to increased intrathoracic pressure , collapse of the lung on the affected side , shifting of the mediastinum , and hemodynamic instability . The patient would present with absent breath sounds on the affected side, hyper-resonance on percussion, and possibly tracheal deviation away from the affected side. Since this patient has equal bilateral breath sounds and no mention of tracheal deviation, tension pneumothorax is less likely.</li><li>• Option A:</li><li>• Tension pneumothorax</li><li>• air enters the pleural space and cannot escape, leading to increased intrathoracic pressure</li><li>• collapse of the lung on the affected side</li><li>• shifting of the mediastinum</li><li>• hemodynamic instability</li><li>• Option B: Simple pneumothorax - A simple pneumothorax involves the presence of air in the pleural space without significant shift of the mediastinum or hemodynamic instability . The patient would typically have decreased breath sounds on the affected side, but the blood pressure would likely remain normal unless there is a large amount of air. The presence of equal breath sounds bilaterally, and the hemodynamic instability (hypotension) makes this unlikely.</li><li>• Option B:</li><li>• Simple pneumothorax</li><li>• presence of air in the pleural space without significant shift of the mediastinum</li><li>• hemodynamic instability</li><li>• Option D: Massive hemothorax - This is the accumulation of a large volume of blood in the pleural cavity , often due to trauma. It would typically present with decreased or absent breath sounds on the affected side, dullness to percussion, and signs of hypovolemia. Given that this patient has normal bilateral breath sounds, this condition is less likely.</li><li>• Option D:</li><li>• Massive hemothorax</li><li>• accumulation of a large volume of blood in the pleural cavity</li><li>• due to trauma.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Beck's triad — hypotension, muffled heart sounds, and distended neck veins —in a patient with a penetrating chest injury .</li><li>➤ Beck's triad</li><li>➤ hypotension, muffled heart sounds, and distended neck veins</li><li>➤ penetrating chest injury</li><li>➤ Cardiac tamponade is compression of the heart by an accumulation of fluid in the pericardial sac . This results in decreased cardiac output due to decreased inflow to the heart. The human pericardial sac is a fixed fibrous structure, and a relatively small amount of blood can restrict cardiac activity and interfere with cardiac filling. Cardiac tamponade most commonly results from penetrating injuries .</li><li>➤ Cardiac tamponade is compression of the heart by an accumulation of fluid in the pericardial sac . This results in decreased cardiac output due to decreased inflow to the heart. The human pericardial sac is a fixed fibrous structure, and a relatively small amount of blood can restrict cardiac activity and interfere with cardiac filling.</li><li>➤ Cardiac tamponade is compression of the heart by an accumulation of fluid in the pericardial sac</li><li>➤ Cardiac tamponade most commonly results from penetrating injuries .</li><li>➤ Cardiac tamponade</li><li>➤ penetrating injuries</li><li>➤ The classic clinical triad of muffled heart sounds, hypotension, and distended veins is not uniformly present with cardiac tamponade. Muffled heart tones are difficult to assess in the noisy resuscitation room, and distended neck veins may be absent due to hypovolemia. Kussmaul’s sign (i.e., a rise in venous pressure with inspiration when breathing spontaneously) is a true paradoxical venous pressure abnormality that is associated with tamponade.</li><li>➤ The classic clinical triad of muffled heart sounds, hypotension, and distended veins is not uniformly present with cardiac tamponade. Muffled heart tones are difficult to assess in the noisy resuscitation room, and distended neck veins may be absent due to hypovolemia. Kussmaul’s sign (i.e., a rise in venous pressure with inspiration when breathing spontaneously) is a true paradoxical venous pressure abnormality that is associated with tamponade.</li><li>➤ The classic clinical triad of muffled heart sounds, hypotension, and distended veins is not uniformly present with cardiac tamponade.</li><li>➤ Ref : ATLS Student Manual 10th Edition Page 69</li><li>➤ Ref</li><li>➤ : ATLS Student Manual 10th Edition Page 69</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 375</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 375</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "After evaluation of a patient of penetrating thoracic trauma, pericardial tamponade was clinically suspected. Patient is hypotensive. What is the next best investigation and the treatment of choice in this case?", "options": [{"label": "A", "text": "eFAST, needle pericardiocentesis", "correct": false}, {"label": "B", "text": "eFAST, sternotomy / left anterolateral thoracotomy", "correct": true}, {"label": "C", "text": "Chest X Ray, needle pericardiocentesis", "correct": false}, {"label": "D", "text": "CT scan, sternotomy / left anterolateral thoracotomy", "correct": false}], "correct_answer": "B. eFAST, sternotomy / left anterolateral thoracotomy", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture15_ytekKgJ.jpg"], "explanation": "<p><strong>Ans. B) e Fast, sternotomy/left anterolateral thoracotomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: e fast, needle pericardiocentesis - Extended Focused Assessment with Sonography for Trauma (e fast) is an appropriate initial investigation as it quickly evaluates for the presence of pericardial fluid and can be performed at the bedside . However, needle pericardiocentesis may not be effective in the context of penetrating trauma because clots in the pericardium may prevent fluid aspiration.</li><li>• Option A:</li><li>• fast, needle pericardiocentesis</li><li>• Extended Focused Assessment with Sonography</li><li>• Trauma</li><li>• initial investigation as it quickly evaluates for the presence of pericardial fluid</li><li>• performed at the bedside</li><li>• Option C: CXR, needle pericardiocentesis - While a chest x-ray (CXR) can provide useful information in the setting of chest trauma , it is less sensitive than eFAST for diagnosing pericardial tamponade . As previously mentioned, needle pericardiocentesis is not the treatment of choice for penetrating injuries.</li><li>• Option C:</li><li>• CXR, needle pericardiocentesis</li><li>• chest x-ray</li><li>• provide useful information in the setting of chest trauma</li><li>• less sensitive than eFAST for diagnosing pericardial tamponade</li><li>• Option D: CT scan sternotomy / left anterolateral thoracotomy - A CT scan can provide comprehensive information about chest injuries but is not the first-line investigation in a hemodynamically unstable patient due to the time it takes to perform and the need to transport the patient to the radiology suite. Operative intervention is appropriate, but eFAST is preferred for the initial evaluation in this acute scenario.</li><li>• Option D:</li><li>• CT scan sternotomy / left anterolateral thoracotomy</li><li>• comprehensive information</li><li>• chest injuries</li><li>• not the first-line investigation in a hemodynamically unstable patient</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ eFAST can be utilized for rapid bedside diagnosis of pericardial tamponade in a patient with thoracic trauma and manage operatively with sternotomy or left anterolateral thoracotomy.</li><li>➤ In penetrating injury to the heart, there is usually a substantial clot in the pericardium, which may prevent aspiration. Pericardiocentesis has NO role in the management of cardiac tamponade secondary to penetrating myocardial injury. The correct immediate treatment is operative, either via a subxiphoid window or by open surgery (sternotomy / left anterolateral thoracotomy) with repair of the heart.</li><li>➤ In penetrating injury to the heart, there is usually a substantial clot in the pericardium, which may prevent aspiration. Pericardiocentesis has NO role in the management of cardiac tamponade secondary to penetrating myocardial injury.</li><li>➤ In penetrating injury to the heart, there is usually a substantial clot in the pericardium, which may prevent aspiration. Pericardiocentesis has NO role in the management of cardiac tamponade secondary to penetrating myocardial injury.</li><li>➤ The correct immediate treatment is operative, either via a subxiphoid window or by open surgery (sternotomy / left anterolateral thoracotomy) with repair of the heart.</li><li>➤ The correct immediate treatment is operative, either via a subxiphoid window or by open surgery (sternotomy / left anterolateral thoracotomy) with repair of the heart.</li><li>➤ Ref : ATLS Student Manual 10th Edition Page 69</li><li>➤ Ref</li><li>➤ : ATLS Student Manual 10th Edition Page 69</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 375</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 375</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following injuries takes the least time to result in death?", "options": [{"label": "A", "text": "Thoracic aortic injury", "correct": false}, {"label": "B", "text": "Extradural hemorrhage", "correct": false}, {"label": "C", "text": "Tension pneumothorax", "correct": false}, {"label": "D", "text": "Airway obstruction", "correct": true}], "correct_answer": "D. Airway obstruction", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-101236.jpg"], "explanation": "<p><strong>Ans. D) Airway obstruction</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Thoracic aortic injury - This injury can lead to rapid blood loss and cardiovascular collapse . Death can be almost immediate if the aorta is completely transected, but if the injury is contained within the layers of the aortic wall, it may take a bit longer for the condition to become fatal.</li><li>• Option A:</li><li>• Thoracic aortic injury</li><li>• injury can lead to rapid blood loss</li><li>• cardiovascular collapse</li><li>• Option B: Extradural hemorrhage - Also known as an epidural hematoma , this condition involves bleeding between the inner surface of the skull and the dura mater . It can lead to death within hours if not treated, as the accumulation of blood can increase intracranial pressure, leading to brain herniation.</li><li>• Option B:</li><li>• Extradural hemorrhage</li><li>• epidural hematoma</li><li>• involves bleeding between the inner surface of the skull and the dura mater</li><li>• Option C: Tension pneumothorax - This condition occurs when air enters the pleural space and cannot escape, leading to increased pressure that compresses the lung and shifts the mediastinum , impairing venous return to the heart. It can result in death fairly rapidly, often within minutes to an hour if untreated.</li><li>• Option C:</li><li>• Tension pneumothorax</li><li>• air enters the pleural space and cannot escape,</li><li>• increased pressure that compresses the lung and shifts the mediastinum</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The given image summarizes the ATLS Primary Survey order of priorities in management-</li><li>➤ Ref : ATLS Student Manual 10th Edition Pages 23-36</li><li>➤ Ref : ATLS Student Manual 10th Edition Pages 23-36</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is not a boundary of the ‘triangle of safety’ for chest tube insertion?", "options": [{"label": "A", "text": "Serratus anterior", "correct": true}, {"label": "B", "text": "Pectoralis major", "correct": false}, {"label": "C", "text": "Latissimus dorsi", "correct": false}, {"label": "D", "text": "5th Intercostal space", "correct": false}], "correct_answer": "A. Serratus anterior", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture16_sk6pctl.jpg"], "explanation": "<p><strong>Ans. A) Serratus anterior</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• The boundaries of the ‘triangle of safety’ are as follows-</li><li>• ‘triangle of safety’</li><li>• Posteriorly- latissimus dorsi</li><li>• Posteriorly- latissimus dorsi</li><li>• Anteriorly- lateral border of pectoralis major</li><li>• Anteriorly- lateral border of pectoralis major</li><li>• Inferiorly - 5th Inter-costal space</li><li>• Inferiorly - 5th Inter-costal space</li><li>• Fig : Triangle of safety for Chest Tube placement</li><li>• Fig</li><li>• : Triangle of safety for Chest Tube placement</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The \"triangle of safety \" is a guideline used in medical procedures to locate a safe area for chest interventions like needle thoracostomy , bordered by the lateral edge of the pectoralis major , the lateral edge of the latissimus dorsi , and a horizontal line at the level of the nipple .</li><li>➤ \"triangle of safety</li><li>➤ used in medical procedures</li><li>➤ locate a safe area for chest interventions</li><li>➤ needle thoracostomy</li><li>➤ bordered by the lateral edge of the pectoralis major</li><li>➤ lateral edge</li><li>➤ latissimus dorsi</li><li>➤ horizontal line</li><li>➤ level of the nipple</li><li>➤ Ref : ATLS Student Manual 10th Edition- Page 346</li><li>➤ Ref</li><li>➤ : ATLS Student Manual 10th Edition- Page 346</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which vessels are most commonly implicated in causing massive hemothorax post blunt trauma to the chest?", "options": [{"label": "A", "text": "Internal mammary arteries", "correct": false}, {"label": "B", "text": "Intercostal vessels", "correct": true}, {"label": "C", "text": "Thoracic aorta", "correct": false}, {"label": "D", "text": "Azygos vein", "correct": false}], "correct_answer": "B. Intercostal vessels", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture17.jpg"], "explanation": "<p><strong>Ans. B) Intercostal vessels</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Internal mammary arteries - These vessels can be damaged during blunt chest trauma , particularly when there are associated sternum fractures . While they can cause significant bleeding, they are less commonly the source of a massive hemothorax compared to intercostal vessels.</li><li>• Option A:</li><li>• Internal mammary arteries</li><li>• vessels can be damaged during blunt chest trauma</li><li>• associated sternum fractures</li><li>• Option C and Option D: Thoracic aorta and Azygous vein : They are uncommonly related to hemothorax .</li><li>• Option C and Option D:</li><li>• Thoracic aorta</li><li>• Azygous vein</li><li>• uncommonly related to hemothorax</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The intercostal vessels are the most common source of bleeding causing massive hemothorax following blunt chest trauma.</li><li>➤ intercostal vessels</li><li>➤ most common source of bleeding</li><li>➤ massive hemothorax following blunt chest trauma.</li><li>➤ Fig: Massive Hemothorax . This condition results from the rapid accumulation of more than 1500 mL of blood or one-third or more of the patient’s blood volume in the chest cavity.</li><li>➤ Fig:</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 375</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 375</li><li>➤ ATLS Student Manual 10th Edition Page 69</li><li>➤ ATLS Student Manual 10th Edition Page 69</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient with stab injury to the chest presented with features of shock, associated with the absence of breath sounds and dullness to percussion on one side of the chest. Chest X-ray showed the picture given below. What is the most probable diagnosis?", "options": [{"label": "A", "text": "Pneumothorax", "correct": false}, {"label": "B", "text": "Traumatic diaphragm rupture", "correct": false}, {"label": "C", "text": "Massive hemothorax", "correct": true}, {"label": "D", "text": "Cardiac tamponade", "correct": false}], "correct_answer": "C. Massive hemothorax", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture18.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Massive hemothorax</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Pneumothorax - Typically presents with absent breath sounds and hyper-resonance to percussion on the affected side , along with a visible rim of air outlining the collapsed lung on the chest X-ray . Shock is not a common feature unless it progresses to a tension pneumothorax.</li><li>• Option A:</li><li>• Pneumothorax</li><li>• absent breath sounds and hyper-resonance</li><li>• percussion on the affected side</li><li>• visible rim of air outlining the collapsed lung on the chest X-ray</li><li>• Option B: Traumatic diaphragm rupture - Usually presents with abdominal contents entering the thoracic cavity , potentially visible on chest X-ray . It may not be immediately associated with shock or absent breath sounds unless there is an associated hemothorax or lung injury.</li><li>• Option B:</li><li>• Traumatic diaphragm rupture</li><li>• abdominal contents entering the thoracic cavity</li><li>• visible on chest X-ray</li><li>• Option D: Cardiac tamponade - Presents with Beck's triad (hypotension, muffled heart sounds, and distended neck veins) and may show an enlarged cardiac silhouette on the chest X-ray , known as the \"water bottle\" sign . The absence of breath sounds is not a feature of tamponade.</li><li>• Option D:</li><li>• Cardiac tamponade</li><li>• Beck's triad</li><li>• enlarged cardiac silhouette on the chest X-ray</li><li>• \"water bottle\" sign</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Massive hemothorax is diagnosed by recognizing shock, absence of breath sounds, and dullness to percussion on one side of the chest in a patient with a stab injury , confirmed by chest X-ray showing opacification of the affected hemithorax.</li><li>➤ Massive hemothorax</li><li>➤ shock, absence of breath sounds, and dullness to percussion on one side of the chest in a patient with a stab injury</li><li>➤ Massive hemothorax results from the rapid accumulation of more than 1500 mL of blood or one- third or more of the patient’s blood volume in the chest cavity .</li><li>➤ Massive hemothorax</li><li>➤ rapid accumulation of more than 1500 mL of blood</li><li>➤ one- third or more of the patient’s blood volume</li><li>➤ chest cavity</li><li>➤ Clinical features:</li><li>➤ Clinical features:</li><li>➤ In these patients, the neck veins may be flat due to severe hypovolemia. A massive hemothorax is suggested when shock is associated with the absence of breath sounds or dullness to percussion on one side of the chest.</li><li>➤ neck veins may be flat due to severe hypovolemia.</li><li>➤ massive hemothorax</li><li>➤ shock is associated with the absence of breath sounds or dullness to percussion on one side of the chest.</li><li>➤ Management:</li><li>➤ Management:</li><li>➤ Massive hemothorax is initially managed by simultaneously restoring blood volume and decompressing the chest cavity. Establish large-caliber intravenous lines, infuse crystalloid, and begin transfusion as soon as possible. A single chest tube is inserted, usually at the fifth intercostal space, just anterior to the mid-axillary line, and rapid restoration of volume continues as decompression of the chest cavity is completed. The immediate return of 1500 mL or more of blood generally indicates the need for urgent thoracotomy.</li><li>➤ Massive hemothorax is initially managed by simultaneously restoring blood volume and decompressing the chest cavity.</li><li>➤ Massive hemothorax is initially managed by simultaneously restoring blood volume and decompressing the chest cavity.</li><li>➤ Establish large-caliber intravenous lines, infuse crystalloid, and begin transfusion as soon as possible.</li><li>➤ Establish large-caliber intravenous lines, infuse crystalloid, and begin transfusion as soon as possible.</li><li>➤ A single chest tube is inserted, usually at the fifth intercostal space, just anterior to the mid-axillary line, and rapid restoration of volume continues as decompression of the chest cavity is completed.</li><li>➤ A single chest tube is inserted, usually at the fifth intercostal space, just anterior to the mid-axillary line, and rapid restoration of volume continues as decompression of the chest cavity is completed.</li><li>➤ The immediate return of 1500 mL or more of blood generally indicates the need for urgent thoracotomy.</li><li>➤ The immediate return of 1500 mL or more of blood generally indicates the need for urgent thoracotomy.</li><li>➤ Ref : ATLS Student Manual 10th Edition- Page 68</li><li>➤ Ref : ATLS Student Manual 10th Edition- Page 68</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 375</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 375</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "About the following scenarios, choose the ones where an urgent thoracotomy is indicated, in a patient of massive hemothorax due to chest trauma? Chest tube output of 1600 mL of blood immediately post insertion Chest tube output of 100 mL/ hr of blood for 3 consecutive hours Co-existing pericardial tamponade", "options": [{"label": "A", "text": "a, b, c", "correct": false}, {"label": "B", "text": "b, c", "correct": false}, {"label": "C", "text": "a, b", "correct": false}, {"label": "D", "text": "a, c", "correct": true}], "correct_answer": "D. a, c", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) a, c</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Indications of urgent thoracotomy in a patient of massive hemothorax-</li><li>• Indications of urgent thoracotomy</li><li>• massive hemothorax-</li><li>• Initial drainage of &gt; 1500 mL of blood after chest tube insertion Ongoing hemorrhage of &gt; 200 mL/hr of blood over 3-4 hrs continuously Co-existing pericardial tamponade</li><li>• Initial drainage of &gt; 1500 mL of blood after chest tube insertion</li><li>• Ongoing hemorrhage of &gt; 200 mL/hr of blood over 3-4 hrs continuously</li><li>• Co-existing pericardial tamponade</li><li>• The persistent need for blood transfusion is also an indication for thoracotomy.</li><li>• persistent need for blood transfusion is also an indication for thoracotomy.</li><li>• Blood in the pleural space should be removed as completely and rapidly as possible to prevent ongoing bleeding, an empyema or fibrothorax later.</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Immediate chest tube output of over 1500 mL of blood post-insertion and the presence of a pericardial tamponade are clear indications for an urgent thoracotomy in the setting of massive hemothorax due to chest trauma.</li><li>• Immediate chest tube output</li><li>• over 1500 mL of blood post-insertion</li><li>• presence of a pericardial tamponade</li><li>• urgent thoracotomy in the setting of massive hemothorax due to chest trauma.</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 375</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Page 375</li><li>• ATLS Student Manual 10th Edition Page 69</li><li>• ATLS Student Manual 10th Edition Page 69</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A victim of RTA was brought into the casualty with shortness of breath and pain in the right upper part of his chest. Inspection revealed bruising over the right chest wall. On palpation, there was associated tenderness over the ribs and a chest X-ray showed the following picture. Which of these is the first step of definitive management in this case?", "options": [{"label": "A", "text": "Chest splinting", "correct": false}, {"label": "B", "text": "Thoracotomy", "correct": false}, {"label": "C", "text": "Opiate analgesia, oxygen, chest physiotherapy", "correct": true}, {"label": "D", "text": "Internal fixation of fractures", "correct": false}], "correct_answer": "C. Opiate analgesia, oxygen, chest physiotherapy", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture19_VspDYf7.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture20_YI6Db18.jpg"], "explanation": "<p><strong>Ans. C) Opiate analgesia, oxygen, chest physiotherapy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Chest splinting - This is not the first step in the management of multiple rib fractures . While it may provide some pain relief, it can also impair respiratory efforts and is not considered a definitive treatment.</li><li>• Option A:</li><li>• Chest splinting</li><li>• not the first step in the management of multiple rib fractures</li><li>• Option B: Thoracotomy - This is a surgical intervention that is not indicated as an initial step in the management of isolated rib fractures . Thoracotomy is reserved for cases where there is a need for surgical repair of internal chest injuries.</li><li>• Option B:</li><li>• Thoracotomy</li><li>• surgical intervention that is not indicated as an initial step in the management of isolated rib fractures</li><li>• Option D: Internal fixation of fractures - This is a more invasive procedure and is generally reserved for severe cases where there is a need for mechanical stabilization of the chest wall , typically when conservative measures have failed or are inadequate due to the severity of the chest wall injury.</li><li>• Option D:</li><li>• Internal fixation of fractures</li><li>• more invasive procedure</li><li>• reserved for severe cases</li><li>• need for mechanical stabilization of the chest wall</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Manage multiple rib fractures initially with opiate analgesia to control pain, oxygen supplementation to ensure adequate oxygenation , and chest physiotherapy to improve ventilation and prevent complications.</li><li>➤ Manage multiple rib fractures</li><li>➤ opiate analgesia to control pain, oxygen supplementation to ensure adequate oxygenation</li><li>➤ chest physiotherapy</li><li>➤ The chest wall shows paradoxical motion of the flail segment . On inspiration, the loose segment is displaced inwards while the rest of the chest wall moves out, and vice-versa. Voluntary splinting of the chest wall due to the pain and this, along with underlying lung contusion can result in hypoxia.</li><li>➤ The chest wall shows paradoxical motion of the flail segment . On inspiration, the loose segment is displaced inwards while the rest of the chest wall moves out, and vice-versa. Voluntary splinting of the chest wall due to the pain and this, along with underlying lung contusion can result in hypoxia.</li><li>➤ chest wall shows paradoxical motion of the flail segment</li><li>➤ Management-</li><li>➤ Management-</li><li>➤ Definitive treatment of flail chest and pulmonary contusion involves ensuring adequate oxygenation, providing analgesia to improve ventilation and chest physiotherapy. Analgesia can be achieved with intravenous narcotics or topical intra-pleural anesthetic administration through an already inserted chest tube. Ventilation is reserved for patients developing respiratory failure despite adequate analgesia and oxygen. Internal fixation of fractures done in selected cases with prolonged mechanical ventilation or severe chest injury and pulmonary contusion.</li><li>➤ Definitive treatment of flail chest and pulmonary contusion involves ensuring adequate oxygenation, providing analgesia to improve ventilation and chest physiotherapy.</li><li>➤ flail chest and pulmonary contusion involves ensuring adequate oxygenation, providing analgesia to improve ventilation and chest physiotherapy.</li><li>➤ Analgesia can be achieved with intravenous narcotics or topical intra-pleural anesthetic administration through an already inserted chest tube.</li><li>➤ Ventilation is reserved for patients developing respiratory failure despite adequate analgesia and oxygen.</li><li>➤ Internal fixation of fractures done in selected cases with prolonged mechanical ventilation or severe chest injury and pulmonary contusion.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 375</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 375</li><li>➤ ATLS Student Manual 10th Edition Page 74</li><li>➤ ATLS Student Manual 10th Edition Page 74</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient with chest trauma was diagnosed with flail chest and an underlying massive lung contusion. Despite adequate analgesia and oxygenation, he continued to stay hypoxic and a diagnosis of respiratory failure was made. What will be your next step in management of this patient?", "options": [{"label": "A", "text": "Chest strapping", "correct": false}, {"label": "B", "text": "Chest tube insertion", "correct": false}, {"label": "C", "text": "Mechanical ventilation", "correct": true}, {"label": "D", "text": "Internal fixation of fractures", "correct": false}], "correct_answer": "C. Mechanical ventilation", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture21.jpg"], "explanation": "<p><strong>Ans. C) Mechanical ventilation</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Chest strapping - This is an outdated management technique for flail chest as it can further restrict ventilation and worsen gas exchange, especially in the setting of underlying lung contusion.</li><li>• Option A:</li><li>• Chest strapping</li><li>• outdated management technique for flail chest</li><li>• Option B : Chest tube insertion - If a pneumothorax or hemothorax is present, which can sometimes occur with significant chest trauma , chest tube insertion would be appropriate. However, in the absence of these conditions and with the primary issue being respiratory failure, a chest tube alone would not address the underlying ventilatory failure.</li><li>• Option B</li><li>• Chest tube insertion</li><li>• pneumothorax or hemothorax is present, which can sometimes occur with significant chest trauma</li><li>• chest tube insertion would be appropriate.</li><li>• Option D: Internal fixation of fractures - Internal fixation may be considered in cases of severe chest wall instability or when prolonged mechanical ventilation is anticipated . However, it is not the initial step in the acute management of respiratory failure due to flail chest.</li><li>• Option D:</li><li>• Internal fixation of fractures</li><li>• considered in cases of severe chest wall instability or when prolonged mechanical ventilation is anticipated</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Initiate mechanical ventilation in patients with flail chest and respiratory failure when conservative measures such as analgesia and oxygenation are insufficient.</li><li>➤ Initiate mechanical ventilation</li><li>➤ flail chest and respiratory failure</li><li>➤ conservative measures such as analgesia and oxygenation are insufficient.</li><li>➤ When two or more ribs (according to ATLS) or three or more ribs (according to Bailey) are fractured in two or more places , it results in a flail chest . The blunt force typically also produces an underlying pulmonary contusion. The chest wall shows paradoxical motion of the flail segment. On inspiration, the loose segment is displaced inwards while the rest of the chest wall moves out, and vice-versa. Voluntary splinting of the chest wall due to the pain and this, along with underlying lung contusion can result in hypoxia.</li><li>➤ When two or more ribs (according to ATLS) or three or more ribs (according to Bailey) are fractured in two or more places , it results in a flail chest . The blunt force typically also produces an underlying pulmonary contusion.</li><li>➤ When two or more ribs</li><li>➤ three or more ribs</li><li>➤ fractured in two or more places</li><li>➤ flail chest</li><li>➤ The chest wall shows paradoxical motion of the flail segment. On inspiration, the loose segment is displaced inwards while the rest of the chest wall moves out, and vice-versa. Voluntary splinting of the chest wall due to the pain and this, along with underlying lung contusion can result in hypoxia.</li><li>➤ Management-</li><li>➤ Management-</li><li>➤ Definitive treatment of flail chest and pulmonary contusion involves ensuring adequate oxygenation , providing analgesia to improve ventilation and chest physiotherapy . Analgesia can be achieved with intravenous narcotics or topical intra-pleural anesthetic administration through an already inserted chest tube. Ventilation is reserved for patients developing respiratory failure despite adequate analgesia and oxygen. Internal fixation of fractures done in select cases with prolonged mechanical ventilation or severe chest injury and pulmonary contusion.</li><li>➤ Definitive treatment of flail chest and pulmonary contusion involves ensuring adequate oxygenation , providing analgesia to improve ventilation and chest physiotherapy .</li><li>➤ Definitive treatment</li><li>➤ flail chest and pulmonary contusion</li><li>➤ ensuring adequate oxygenation</li><li>➤ analgesia to improve ventilation and chest physiotherapy</li><li>➤ Analgesia can be achieved with intravenous narcotics or topical intra-pleural anesthetic administration through an already inserted chest tube.</li><li>➤ Ventilation is reserved for patients developing respiratory failure despite adequate analgesia and oxygen.</li><li>➤ Internal fixation of fractures done in select cases with prolonged mechanical ventilation or severe chest injury and pulmonary contusion.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 375</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 375</li><li>➤ ATLS Student Manual 10th Edition Page 74</li><li>➤ ATLS Student Manual 10th Edition Page 74</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient came with blunt trauma to the right side of abdomen. There was associated right sided lower ribs fracture. He was hemodynamically unstable and hence taken up for surgery. At the time of laparotomy, which of these will not be beneficial to control a liver bleed?", "options": [{"label": "A", "text": "Packing", "correct": false}, {"label": "B", "text": "Plugging any defects with a Sengstaken Blakemore tube", "correct": false}, {"label": "C", "text": "Placing omentum into liver cracks", "correct": true}, {"label": "D", "text": "Clamping hepatoduodenal ligament", "correct": false}], "correct_answer": "C. Placing omentum into liver cracks", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture23.jpg"], "explanation": "<p><strong>Ans. C) Placing omentum into liver cracks</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Packing involves the placement of gauze or other materials into the liver laceration to provide pressure and tamponade bleeding . It is a commonly used technique to control hepatic bleeding during laparotomy in hemodynamically unstable patients with liver injury.</li><li>• Option A: Packing</li><li>• placement of gauze or other materials into the liver laceration to provide pressure and tamponade bleeding</li><li>• Option B: Plugging defects in the liver with a Sengstaken Blakemore tube can be an effective method to stop bleeding from liver injuries during surgery . The tube is inflated within the liver laceration to provide tamponade and occlude bleeding vessels.</li><li>• Option B: Plugging defects</li><li>• liver with a Sengstaken Blakemore tube can be an effective method to stop bleeding from liver injuries during surgery</li><li>• Option D: Clamping the hepatoduodenal ligament known as the Pringle maneuver , is a method to temporarily control inflow to the liver by occluding the hepatic artery and portal vein . This manoeuvre helps to reduce blood flow into the liver, thereby decreasing bleeding from hepatic injuries.</li><li>• Option D: Clamping</li><li>• hepatoduodenal ligament</li><li>• Pringle maneuver</li><li>• method to temporarily control inflow to the liver by occluding the hepatic artery and portal vein</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• The techniques used to control liver bleeding during laparotomy in hemodynamically unstable patients with blunt abdominal trauma , involve methods such as packing, plugging defects with a Sengstaken Blakemore tube , and clamping the hepatoduodenal ligament , placing omentum into liver cracks is not a standard maneuver for this purpose.</li><li>• techniques used to control liver bleeding during laparotomy in hemodynamically unstable patients with blunt abdominal trauma</li><li>• packing, plugging defects with a Sengstaken Blakemore tube</li><li>• clamping the hepatoduodenal ligament</li><li>• Ref : Bailey and Love ’ s Short Practice of Surgery 28th Edition Page 380</li><li>• Ref</li><li>• : Bailey and Love</li><li>• ’</li><li>• s Short Practice of Surgery 28th Edition Page 380</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following patients of blunt solid organ injury will you not consider taking up for laparotomy?", "options": [{"label": "A", "text": "A 45-year-old man who has a shattered spleen on CECT", "correct": false}, {"label": "B", "text": "A 30-year-old man whose hemoglobin and hematocrit are dropping rapidly despite adequate conservative treatment of grade 2 splenic trauma", "correct": false}, {"label": "C", "text": "A patient with features of peritonitis", "correct": false}, {"label": "D", "text": "A patient who is hemodynamically stable with grade 2 liver injury", "correct": true}], "correct_answer": "D. A patient who is hemodynamically stable with grade 2 liver injury", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) A patient who is hemodynamically stable with grade 2 liver injury</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: A shattered spleen on CECT indicates a significant splenic injury , which may necessitate intervention such as laparotomy , particularly if the patient becomes hemodynamically unstable or shows signs of ongoing bleeding despite conservative management.</li><li>• Option A:</li><li>• shattered spleen on CECT</li><li>• significant splenic injury</li><li>• necessitate intervention such as laparotomy</li><li>• Option B: Rapidly dropping hemoglobin and hematocrit despite conservative treatment suggest ongoing bleeding from the splenic injury . This patient may require intervention such as angioembolization or laparotomy to control bleeding and prevent further deterioration.</li><li>• Option B:</li><li>• Rapidly dropping hemoglobin and hematocrit</li><li>• conservative treatment</li><li>• ongoing bleeding from the splenic injury</li><li>• Option C: Peritonitis is a sign of intra-abdominal perforation of hollow organ , which warrants surgical repair.</li><li>• Option C:</li><li>• Peritonitis is a sign of intra-abdominal perforation of hollow organ</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ A hemodynamically stable patient with a grade 2 liver injury is less likely to require immediate laparotomy compared to patients with other indications such as hemodynamic instability, ongoing bleeding despite conservative management, or signs of peritonitis.</li><li>➤ hemodynamically stable patient with a grade 2 liver injury</li><li>➤ less likely to require immediate laparotomy</li><li>➤ Indications of laparotomy in abdomen trauma-</li><li>➤ Blunt abdominal trauma with hypotension, with a positive FAST or clinical evidence of intraperitoneal bleeding, or without another source of bleeding Hypotension with an abdominal wound that penetrates the anterior fascia Gunshot wounds that traverse the peritoneal cavity Evisceration Bleeding from the stomach, rectum, or genitourinary tract following penetrating trauma Peritonitis Free air, retroperitoneal air, or rupture of the hemidiaphragm Contrast-enhanced CT that demonstrates ruptured gastrointestinal tract, intraperitoneal bladder injury, renal pedicle injury, or severe visceral parenchymal injury after blunt or penetrating trauma Blunt or penetrating abdominal trauma with aspiration of gastrointestinal contents, vegetable fibers, or bile from DPL, or aspiration of 10 cc or more of blood in hemodynamically abnormal patients.</li><li>➤ Blunt abdominal trauma with hypotension, with a positive FAST or clinical evidence of intraperitoneal bleeding, or without another source of bleeding</li><li>➤ Hypotension with an abdominal wound that penetrates the anterior fascia</li><li>➤ Gunshot wounds that traverse the peritoneal cavity</li><li>➤ Evisceration</li><li>➤ Bleeding from the stomach, rectum, or genitourinary tract following penetrating trauma</li><li>➤ Peritonitis</li><li>➤ Free air, retroperitoneal air, or rupture of the hemidiaphragm</li><li>➤ Contrast-enhanced CT that demonstrates ruptured gastrointestinal tract, intraperitoneal bladder injury, renal pedicle injury, or severe visceral parenchymal injury after blunt or penetrating trauma</li><li>➤ Blunt or penetrating abdominal trauma with aspiration of gastrointestinal contents, vegetable fibers, or bile from DPL, or aspiration of 10 cc or more of blood in hemodynamically abnormal patients.</li><li>➤ Ref : ATLS Student Manual 10th Edition Page 95.</li><li>➤ Ref</li><li>➤ : ATLS Student Manual 10th Edition Page 95.</li><li>➤ Sabiston Textbook of Surgery Page 436</li><li>➤ Sabiston Textbook of Surgery Page 436</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Regarding trauma to the liver, choose the incorrect statement:", "options": [{"label": "A", "text": "Blunt trauma generally occurs due to compression between the impacting object and the rib cage or vertebrae.", "correct": false}, {"label": "B", "text": "Investigation of choice in a stable patient is CT scan.", "correct": false}, {"label": "C", "text": "If after Pringle’s manoeuvre, bleeding does not stop, the source is likely to be hepatic veins.", "correct": false}, {"label": "D", "text": "The hepatic artery and portal vein both can be tied off if damaged.", "correct": true}], "correct_answer": "D. The hepatic artery and portal vein both can be tied off if damaged.", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) The hepatic artery and portal vein both can be tied off if damaged.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Blunt trauma often results from compressive forces exerted on the liver between an impacting object and the rib cage or vertebrae. This can lead to liver injury , including lacerations or contusions.</li><li>• Option A: Blunt trauma often results from compressive forces exerted on the liver between an impacting object and the rib cage or vertebrae.</li><li>• lead to liver injury</li><li>• Option B: In stable patients with suspected liver trauma , CECT scan is the investigation of choice . It provides detailed imaging of the liver injury and adjacent structures, aiding in diagnosis and guiding management decisions.</li><li>• Option B:</li><li>• stable patients</li><li>• suspected liver trauma</li><li>• CECT scan is the investigation of choice</li><li>• Option C: After performing the Pringle maneuver , which involves compression of the portal triad to reduce arterial and portal venous inflow into the liver , persistent bleeding may indicate injury to hepatic veins rather than the portal triad.</li><li>• Option C:</li><li>• Pringle maneuver</li><li>• compression of the portal triad to reduce arterial and portal venous inflow into the liver</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Direct damage to the hepatic artery may require ligation , but damage to the portal vein must be repaired rather than tied off due to the associated mortality risk , emphasizing appropriate management of vascular injuries in liver trauma.</li><li>➤ Direct damage to the hepatic artery</li><li>➤ require ligation</li><li>➤ damage to the portal vein must be repaired rather than tied off</li><li>➤ associated mortality risk</li><li>➤ The inflow from the portal triad is controlled by a Pringle ’ s manoeuvre, with direct compression of the portal triad, either digitally or using a soft clamp. This has the effect of reducing arterial and portal venous inflow into the liver, although it does not control the backflow from the inferior vena cava and hepatic veins. If there has been direct damage to the hepatic artery, it can be tied off. Damage to the portal vein must be repaired (and not tied off), as tying of the portal vein carries a greater than 50% mortality rate.</li><li>➤ The inflow from the portal triad is controlled by a Pringle ’ s manoeuvre, with direct compression of the portal triad, either digitally or using a soft clamp. This has the effect of reducing arterial and portal venous inflow into the liver, although it does not control the backflow from the inferior vena cava and hepatic veins.</li><li>➤ If there has been direct damage to the hepatic artery, it can be tied off. Damage to the portal vein must be repaired (and not tied off), as tying of the portal vein carries a greater than 50% mortality rate.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 380</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 380</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Classify the following statements as true or false: Small bowel injuries need urgent repair. Colon injuries with relatively little contamination and satisfactory viability can be repaired primarily.", "options": [{"label": "A", "text": "T T", "correct": true}, {"label": "B", "text": "T F", "correct": false}, {"label": "C", "text": "F F", "correct": false}, {"label": "D", "text": "F T", "correct": false}], "correct_answer": "A. T T", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Both these statements are true.</li><li>• Small bowel injuries need urgent repair .</li><li>• Small bowel injuries need urgent repair</li><li>• Small bowel injuries often require urgent repair due to the risk of significant complications such as peritonitis, sepsis, and bowel necrosis if left untreated. Delay in repair can lead to further deterioration of the patient's condition and increased morbidity and mortality.</li><li>• Colon injuries with relatively little contamination and satisfactory viability can be repaired primarily .</li><li>• Colon injuries with relatively little contamination and satisfactory viability can be repaired primarily</li><li>• If, however, there is extensive contamination, the patient is physiologically compromised or the bowel is of doubtful viability, then the bowel can be closed off. A de-functioning colostomy can be formed later or the bowel re-anastomosed once the patient is stable.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Small bowel injuries need urgent repair and colon injuries with relatively little contamination and satisfactory viability can be repaired primarily .</li><li>➤ Small bowel injuries need urgent repair and colon injuries with relatively little contamination and satisfactory viability can be repaired primarily</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 381.</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 381.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the correct statement regarding retroperitoneal hematomas:", "options": [{"label": "A", "text": "Zone 1 injuries should always be explored.", "correct": false}, {"label": "B", "text": "Zone 2 injuries should always be explored.", "correct": false}, {"label": "C", "text": "Zone 3 injuries are rarely explored, only if expanding hematoma is present.", "correct": false}, {"label": "D", "text": "A and C", "correct": true}], "correct_answer": "D. A and C", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture24.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/21/10.jpg"], "explanation": "<p><strong>Ans. D) A and C</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In management of retroperitoneal hematomas , Zone 1 injuries should generally be explored due to their central location and potential for significant injury , Zone 3 injuries are typically explored only if there are signs of active bleeding or expanding hematoma.</li><li>➤ management of retroperitoneal hematomas</li><li>➤ Zone 1 injuries</li><li>➤ explored due to their central location and potential for significant injury</li><li>➤ Zone 3 injuries</li><li>➤ explored only if there are signs of active bleeding or expanding hematoma.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 382</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 382</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient of a motorcycle accident came with blunt trauma to left side of abdomen. After initial management, CECT was done, which showed hilar splenic injury. Which of these is the least preferred in the management of the patient ?", "options": [{"label": "A", "text": "Splenectomy", "correct": false}, {"label": "B", "text": "Splenorrhaphy", "correct": false}, {"label": "C", "text": "Embolization", "correct": false}, {"label": "D", "text": "Damage control surgery", "correct": true}], "correct_answer": "D. Damage control surgery", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Damage control surgery</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Splenectomy may be indicated in cases of severe splenic injury that cannot be managed conservatively or repaired with splenorrhaphy . While splenectomy is a viable option in certain cases, it is not the least preferred option in this scenario.</li><li>• Option A: Splenectomy</li><li>• indicated in cases of severe splenic injury</li><li>• cannot be managed conservatively or repaired with splenorrhaphy</li><li>• Option B: Splenorrhaphy refers to the surgical repair of the spleen and is typically preferred over splenectomy when feasible , as it preserves splenic function . However, the choice between splenorrhaphy and other interventions depends on the severity and location of the splenic injury.</li><li>• Option B: Splenorrhaphy</li><li>• surgical repair of the spleen</li><li>• typically preferred over splenectomy when feasible</li><li>• preserves splenic function</li><li>• Option C: Embolization involves the insertion of materials , such as coils or particles, into the blood vessels supplying the spleen to occlude bleeding vessels and stop hemorrhage . It is often a preferred option for patients with splenic injuries who are hemodynamically stable and have evidence of ongoing bleeding, particularly when the injury is amenable to this intervention.</li><li>• Option C: Embolization</li><li>• insertion of materials</li><li>• coils or particles, into the blood vessels supplying the spleen to occlude bleeding vessels and stop hemorrhage</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The least preferred option for management of hilar splenic injury in a hemodynamically stable patient with blunt abdominal trauma is damage control surgery .</li><li>➤ least preferred option for management of hilar splenic injury</li><li>➤ hemodynamically stable patient</li><li>➤ blunt abdominal trauma is damage control surgery</li><li>➤ Management of solid organ injury in blunt trauma:</li><li>➤ patient unstable with FAST positive- do laparotomy Stable → CECT and decide based on grade</li><li>➤ patient unstable with FAST positive- do laparotomy</li><li>➤ Stable → CECT and decide based on grade</li><li>➤ Grade 1,2,3 - conservative Rx</li><li>➤ Grade 4,5 /contrast extravasation ---angioembolisation /laparotomy</li><li>➤ At any stage if patient deterioration (drop in Hb/worsening of Hb or clinical deterioration)—angio-embolization/laparotomy</li><li>➤ Ref : Sabiston Textbook of Surgery 20th Edition Page 436</li><li>➤ Ref</li><li>➤ : Sabiston Textbook of Surgery 20th Edition Page 436</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient following a vehicular collision came to the ER. On examination, the resident found a gross difference in BP of upper and lower limbs. The X-ray showed widening of the mediastinum. Identify the false statement regarding the condition?", "options": [{"label": "A", "text": "The diagnosis is traumatic aortic injury", "correct": false}, {"label": "B", "text": "Investigation of choice (IOC) in a hemodynamically unstable patient of aortic injury is CT scan", "correct": true}, {"label": "C", "text": "First step in management is BP control (target SBP &lt; 120 mm Hg)", "correct": false}, {"label": "D", "text": "An endo-vascular stent can be placed or the tear may be operatively repaired", "correct": false}], "correct_answer": "B. Investigation of choice (IOC) in a hemodynamically unstable patient of aortic injury is CT scan", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) IOC in a hemodynamically unstable patient of aortic injury is CT scan.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: The diagnosis is traumatic aortic injury - This statement is true . Traumatic aortic injury is a common cause of sudden death after high-impact trauma such as a vehicular collision, and the symptoms described, such as a gross difference in blood pressure between limbs and a widened mediastinum on X-ray, are indicative of this diagnosis.</li><li>• Option A:</li><li>• The diagnosis is traumatic aortic injury</li><li>• true</li><li>• Option C: First step in management is BP control (target SBP &lt; 120 mm Hg) - This statement is true . Blood pressure control is critical in managing traumatic aortic injury to reduce the risk of aortic rupture. Medications to control the blood pressure and heart rate are often used to decrease the shear forces against the aortic wall.</li><li>• Option C:</li><li>• First step in management is BP control (target SBP &lt; 120 mm Hg)</li><li>• true</li><li>• Option D: Thereafter, an endo-vascular stent can be placed or the tear may be operatively repaired - This statement is true. Once the patient is hemodynamically stable and the blood pressure is controlled, definitive management may involve the placement of an endovascular stent or open surgical repair of the aortic injury.</li><li>• Option D:</li><li>• Thereafter, an endo-vascular stent can be placed or the tear may be operatively repaired</li><li>• true.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In a hemodynamically unstable patient with suspected traumatic aortic injury , transoesophageal echocardiography , not a CT scan , is the preferred initial imaging modality , followed by blood pressure control and potential endovascular or surgical repair .</li><li>➤ hemodynamically unstable patient with suspected traumatic aortic injury</li><li>➤ transoesophageal echocardiography</li><li>➤ not a CT scan</li><li>➤ preferred initial imaging modality</li><li>➤ blood pressure control and potential endovascular or surgical repair</li><li>➤ Traumatic aortic rupture is a common cause of sudden death after a vehicle collision or fall from a great height. The vessel is relatively fixed distal to the ligamentum arteriosum, just distal to the origin of the left subclavian artery. The shear forces from a sudden impact disrupt the intima and media. If the adventitia is intact, the patient may remain physiologically uncompromised. Thoracic aortic injury should be clinically suspected in patients with gross asymmetry in systolic blood pressure (between the two upper limbs, or between upper and lower limbs), widened pulse pressure and chest wall contusion. Erect chest radiography can also suggest thoracic aortic disruption, the most common radiological finding being a widened mediastinum. The diagnosis is confirmed by a CT scan of the mediastinum if the patient is stable. otherwise, in an unstable patient , trans-esophageal echocardiography is the investigation of choice. In the presence of thoracic aortic injury, initial management consists of control of the systolic arterial blood pressure (to less than 120 mmHg). Thereafter, an endovascular intra-aortic stent can be placed, or the tear can be operatively repaired.</li><li>➤ Traumatic aortic rupture is a common cause of sudden death after a vehicle collision or fall from a great height. The vessel is relatively fixed distal to the ligamentum arteriosum, just distal to the origin of the left subclavian artery.</li><li>➤ The shear forces from a sudden impact disrupt the intima and media. If the adventitia is intact, the patient may remain physiologically uncompromised.</li><li>➤ Thoracic aortic injury should be clinically suspected in patients with gross asymmetry in systolic blood pressure (between the two upper limbs, or between upper and lower limbs), widened pulse pressure and chest wall contusion.</li><li>➤ Erect chest radiography can also suggest thoracic aortic disruption, the most common radiological finding being a widened mediastinum.</li><li>➤ The diagnosis is confirmed by a CT scan of the mediastinum if the patient is stable. otherwise, in an unstable patient , trans-esophageal echocardiography is the investigation of choice.</li><li>➤ unstable patient</li><li>➤ trans-esophageal echocardiography is the investigation of choice.</li><li>➤ In the presence of thoracic aortic injury, initial management consists of control of the systolic arterial blood pressure (to less than 120 mmHg). Thereafter, an endovascular intra-aortic stent can be placed, or the tear can be operatively repaired.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 376.</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 376.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which is the most accurate investigation for diaphragmatic rupture following trauma?", "options": [{"label": "A", "text": "CT scan", "correct": false}, {"label": "B", "text": "USG", "correct": false}, {"label": "C", "text": "Chest X-ray", "correct": false}, {"label": "D", "text": "Laparoscopy", "correct": true}], "correct_answer": "D. Laparoscopy", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Laparoscopy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: CT scan - While CT scans are highly useful for visualizing injuries within the chest and abdomen, small tears in the diaphragm can be missed , especially if the patient is supine.</li><li>• Option A:</li><li>• CT scan</li><li>• small tears in the diaphragm can be missed</li><li>• Option B: USG (Ultrasound) - Ultrasound can be useful in the diagnosis of diaphragmatic rupture in certain situations, especially when free fluid is present , but it is operator-dependent and less sensitive than other modalities.</li><li>• Option B:</li><li>• USG (Ultrasound)</li><li>• diagnosis of diaphragmatic rupture</li><li>• free fluid is present</li><li>• Option C: Chest X-ray - A Chest X-ray can show indirect signs of diaphragmatic rupture, such as the presence of abdominal contents in the chest cavity , but it is not definitive and can miss injuries, especially if no herniation has yet occurred.</li><li>• Option C:</li><li>• Chest X-ray</li><li>• indirect signs of diaphragmatic rupture,</li><li>• presence of abdominal contents in the chest cavity</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 377.</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 377.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient with trauma to the chest and multiple rib fractures presented with worsening hypoxia for the first 24-48 hours and hemoptysis. What would you suspect in this patient?", "options": [{"label": "A", "text": "Pulmonary contusion", "correct": true}, {"label": "B", "text": "Simple pneumothorax", "correct": false}, {"label": "C", "text": "Diaphragmatic rupture", "correct": false}, {"label": "D", "text": "Myocardial contusion", "correct": false}], "correct_answer": "A. Pulmonary contusion", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Pulmonary contusion</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Simple pneumothorax - While a pneumothorax can occur with rib fractures , it usually presents with sudden onset of dyspnea and decreased breath sounds on the affected side , rather than progressive worsening of hypoxia and is not typically associated with hemoptysis.</li><li>• Option B:</li><li>• Simple pneumothorax</li><li>• pneumothorax can occur with rib fractures</li><li>• presents with sudden onset of dyspnea</li><li>• decreased breath sounds on the affected side</li><li>• Option C: Diaphragmatic rupture - This condition could present with respiratory compromise due to herniation of abdominal contents into the thoracic cavity , but it is less likely to cause hemoptysis and would not typically cause a progressive worsening of hypoxia over the first 24–48 hours.</li><li>• Option C:</li><li>• Diaphragmatic rupture</li><li>• respiratory compromise due to herniation of abdominal contents into the thoracic cavity</li><li>• Option D: Myocardial contusion - This refers to bruising of the heart muscle , which can result from blunt chest trauma. It may lead to arrhythmias or cardiac failure but is not typically associated with progressive hypoxemia or hemoptysis.</li><li>• Option D:</li><li>• Myocardial contusion</li><li>• bruising of the heart muscle</li><li>• result from blunt chest trauma.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The presence of worsening hypoxia and hemoptysis following blunt chest trauma with rib fractures is most suggestive of a pulmonary contusion , which can be confirmed with imaging such as a contrast CT scan .</li><li>➤ presence of worsening hypoxia and hemoptysis</li><li>➤ blunt chest trauma with rib fractures</li><li>➤ suggestive of a pulmonary contusion</li><li>➤ imaging such as a contrast CT scan</li><li>➤ Pulmonary contusion occurs more frequently following blunt trauma, and is usually associated with a flail segment or fractured ribs. This is a very common, potentially lethal injury and the major cause of hypoxaemia after blunt trauma. The natural progression of pulmonary contusion is worsening hypoxaemia for the first 24–48 hours. Chest radiographic findings may be typically delayed. Contrast CT scanning can be confirmatory. Hemoptysis or blood in the endotracheal tube is a sign of pulmonary contusion. In mild contusion, the treatment is oxygen administration, pulmonary toilet and adequate analgesia. In more severe cases mechanical ventilation is necessary.</li><li>➤ Pulmonary contusion occurs more frequently following blunt trauma, and is usually associated with a flail segment or fractured ribs. This is a very common, potentially lethal injury and the major cause of hypoxaemia after blunt trauma.</li><li>➤ The natural progression of pulmonary contusion is worsening hypoxaemia for the first 24–48 hours.</li><li>➤ Chest radiographic findings may be typically delayed. Contrast CT scanning can be confirmatory. Hemoptysis or blood in the endotracheal tube is a sign of pulmonary contusion.</li><li>➤ In mild contusion, the treatment is oxygen administration, pulmonary toilet and adequate analgesia. In more severe cases mechanical ventilation is necessary.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 377.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 377.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient of RTA comes to the casualty with blunt trauma to the abdomen. Which is the most commonly injured structure?", "options": [{"label": "A", "text": "Liver", "correct": false}, {"label": "B", "text": "Small bowel", "correct": false}, {"label": "C", "text": "Spleen", "correct": true}, {"label": "D", "text": "Colon", "correct": false}], "correct_answer": "C. Spleen", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• In patients who sustain blunt trauma , the organs most frequently injured are the spleen (40% to 55%), liver (35% to 45%), and small bowel (5% to 10%). Additionally, there is a 15% incidence of retroperitoneal hematoma in patients who undergo laparotomy for</li><li>• patients who sustain blunt trauma</li><li>• organs most frequently injured</li><li>• spleen</li><li>• liver</li><li>• small bowel</li><li>• 15% incidence of retroperitoneal hematoma</li><li>• patients who undergo laparotomy for</li><li>• blunt trauma .</li><li>• blunt trauma</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Most frequently injured structure in blunt trauma to abdomen is spleen .</li><li>➤ Most frequently injured structure</li><li>➤ blunt trauma to abdomen is spleen</li><li>➤ Ref : ATLS Student Manual 10th Edition Page 85</li><li>➤ Ref</li><li>➤ : ATLS Student Manual 10th Edition Page 85</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "The victim of a violent gun-shooting incident was brought to the casualty. Which is the organ most commonly injured in gunshot injuries?", "options": [{"label": "A", "text": "Small bowel", "correct": true}, {"label": "B", "text": "Liver", "correct": false}, {"label": "C", "text": "Aorta", "correct": false}, {"label": "D", "text": "Transverse colon", "correct": false}], "correct_answer": "A. Small bowel", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Gunshot wounds most commonly injure the small bowel (50%), colon (40%), liver (30%), and abdominal vascular structures (25%).</li><li>• Gunshot wounds</li><li>• injure the small bowel</li><li>• colon</li><li>• liver</li><li>• abdominal vascular structures</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Small bowel is the organ most commonly injured in gunshot incidents.</li><li>➤ Small bowel</li><li>➤ organ most commonly injured in gunshot incidents.</li><li>➤ Ref : ATLS Student Manual 10th Edition Page 85</li><li>➤ Ref</li><li>➤ : ATLS Student Manual 10th Edition Page 85</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient with stab injury presented to the casualty. He had the following picture on examination. What will be your next step?", "options": [{"label": "A", "text": "CECT", "correct": false}, {"label": "B", "text": "Exploratory laparotomy", "correct": true}, {"label": "C", "text": "MRI", "correct": false}, {"label": "D", "text": "Close wound and suture", "correct": false}], "correct_answer": "B. Exploratory laparotomy", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture22.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Given scenario indicates penetrating injury with protrusion of omentum (Evisceration) from the wound.</li><li>• Given scenario indicates penetrating injury with protrusion of omentum (Evisceration) from the wound.</li><li>• Explanation:</li><li>• Explanation:</li><li>• Option A: CECT (Contrast-enhanced computed tomography) While CECT is a valuable imaging modality in assessing abdominal trauma , particularly in stable patients , it may not be the immediate next step in management for a patient with a stab wound with evisceration. In such cases, exploratory laparotomy is often indicated for both diagnostic and therapeutic purposes.</li><li>• Option A:</li><li>• CECT</li><li>• valuable imaging modality in assessing abdominal trauma</li><li>• stable patients</li><li>• Option C: MRI (Magnetic resonance imaging) While MRI may provide detailed imaging of abdominal structures , it is not typically the initial diagnostic modality chosen in acute trauma situations.</li><li>• Option C:</li><li>• MRI</li><li>• MRI may provide detailed imaging of abdominal structures</li><li>• Option D: Close wound and suture Simply closing the wound and suturing it without further assessment would be inappropriate , especially in the presence of signs suggesting intra-abdominal injury such as omental protrusion seen here.</li><li>• Option D:</li><li>• Close wound and suture</li><li>• Simply closing the wound and suturing it without further assessment would be inappropriate</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Exploratory laparotomy is indicated in patients with penetrating abdominal trauma , particularly when signs of evisceration, peritonitis, hypotension, or other specific indications are present , highlighting the importance of prompt surgical intervention for diagnostic and therapeutic purposes.</li><li>➤ Exploratory laparotomy</li><li>➤ patients with penetrating abdominal trauma</li><li>➤ signs of evisceration, peritonitis, hypotension, or other specific indications are present</li><li>➤ Indications of laparotomy in penetrating abdomen trauma:</li><li>➤ Gunshot wounds that traverse the peritoneal cavity Evisceration Bleeding from the stomach, rectum, or genitourinary tract following penetrating trauma Peritonitis Hypotension with an abdominal wound that penetrates the anterior fascia</li><li>➤ Gunshot wounds that traverse the peritoneal cavity</li><li>➤ Evisceration</li><li>➤ Bleeding from the stomach, rectum, or genitourinary tract following penetrating trauma</li><li>➤ Peritonitis</li><li>➤ Hypotension with an abdominal wound that penetrates the anterior fascia</li><li>➤ Other indications for laparotomy in abdominal trauma (blunt or penetrating):</li><li>➤ Free air, retroperitoneal air, or rupture of the hemidiaphragm Contrast-enhanced CT that demonstrates ruptured gastrointestinal tract, intraperitoneal bladder injury, renal pedicle injury, or severe visceral parenchymal injury after blunt or penetrating trauma Blunt or penetrating abdominal trauma with aspiration of gastrointestinal contents, vegetable fibers, or bile from DPL, or aspiration of 10 cc or more of blood in hemodynamically abnormal patients. Blunt abdominal trauma with hypotension, with a positive FAST or clinical evidence of intraperitoneal bleeding, or without another source of bleeding</li><li>➤ Free air, retroperitoneal air, or rupture of the hemidiaphragm</li><li>➤ Contrast-enhanced CT that demonstrates ruptured gastrointestinal tract, intraperitoneal bladder injury, renal pedicle injury, or severe visceral parenchymal injury after blunt or penetrating trauma</li><li>➤ Blunt or penetrating abdominal trauma with aspiration of gastrointestinal contents, vegetable fibers, or bile from DPL, or aspiration of 10 cc or more of blood in hemodynamically abnormal patients.</li><li>➤ Blunt abdominal trauma with hypotension, with a positive FAST or clinical evidence of intraperitoneal bleeding, or without another source of bleeding</li><li>➤ Ref : ATLS Student Manual 10th Edition Page 95.</li><li>➤ Ref : ATLS Student Manual 10th Edition Page 95.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient of RTA presented to the casualty with blunt trauma to the abdomen. He was hemodynamically stable. CT scan revealed splenic laceration of 2 cm not involving any trabecular vessel. What is the management of choice?", "options": [{"label": "A", "text": "Urgent laparotomy", "correct": false}, {"label": "B", "text": "Conservative management", "correct": true}, {"label": "C", "text": "Repeat CT scan", "correct": false}, {"label": "D", "text": "Laparoscopy", "correct": false}], "correct_answer": "B. Conservative management", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A : Urgent laparotomy is not typically indicated . Laparotomy is usually reserved for patients who are hemodynamically unstable, have evidence of ongoing bleeding, or have other indications such as peritonitis or evisceration.</li><li>• Option A</li><li>• Urgent laparotomy</li><li>• not typically indicated</li><li>• Option C: While repeat CT scan may be considered in some cases of splenic injury , particularly if there are concerns about ongoing bleeding or worsening of the injury , it is not the immediate management of choice in a hemodynamically stable patient with a grade 2 splenic laceration.</li><li>• Option C: While repeat CT scan</li><li>• some cases of splenic injury</li><li>• there are concerns about ongoing bleeding or worsening of the injury</li><li>• Option D: Laparoscopy may have a role in selected cases of splenic injury for both diagnostic and therapeutic purposes , but it is not typically the primary management choice for a grade 2 splenic laceration in a hemodynamically stable patient. Conservative management is usually preferred in such cases.</li><li>• Option D: Laparoscopy</li><li>• role in selected cases of splenic injury for both diagnostic and therapeutic purposes</li><li>• not typically the primary management choice for a grade 2 splenic laceration</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Conservative management is the appropriate approach for hemodynamically stable patients with grade 2 splenic injuries .</li><li>➤ Conservative management</li><li>➤ appropriate approach for hemodynamically stable patients</li><li>➤ grade 2 splenic injuries</li><li>➤ AAST grades on CECT abdomen</li><li>➤ Spleen</li><li>➤ Liver</li><li>➤ Kidney</li><li>➤ 1</li><li>➤ Laceration &lt;1cm</li><li>➤ Same as spleen 1</li><li>➤ No laceration only hematoma</li><li>➤ 2</li><li>➤ Laceration 1-3cm</li><li>➤ Same as spleen 2</li><li>➤ Laceration &lt;1cm</li><li>➤ 3</li><li>➤ Laceration &gt;3cm</li><li>➤ Same as spleen 3</li><li>➤ Laceration &gt;1cm</li><li>➤ 4</li><li>➤ Peri hilar / branch injuries</li><li>➤ One lobe 25-75% injured</li><li>➤ Same as grade 4 spleen/ tear extends up to pelvic calyx (urinary leak)</li><li>➤ 5</li><li>➤ Hilum / fully shattered spleen</li><li>➤ One lobe &gt;75% injured</li><li>➤ Shattered / major pedicle injury</li><li>➤ 6</li><li>➤ Avulsed liver / major pedicle injury</li><li>➤ Ref : Sabiston Textbook of Surgery 20th Edition Page 435</li><li>➤ Ref</li><li>➤ : Sabiston Textbook of Surgery 20th Edition Page 435</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient was admitted following circumferential abdominal burns with eschar formation. His intra-abdominal pressure is found to be 26 mm Hg. Grade his abdominal hypertension:", "options": [{"label": "A", "text": "Grade 2", "correct": false}, {"label": "B", "text": "Grade 4", "correct": true}, {"label": "C", "text": "Grade 3", "correct": false}, {"label": "D", "text": "Grade 1", "correct": false}], "correct_answer": "B. Grade 4", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-102112.jpg"], "explanation": "<p><strong>Ans. B)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Normal intraabdominal pressure is 5-7 mm Hg .</li><li>• Normal intraabdominal pressure is 5-7 mm Hg</li><li>• Measurement of bladder pressure (intravesical) is the standard method used to screen for IAH and abdominal compartment syndrome.</li><li>• Measurement of bladder pressure</li><li>• standard method used to screen for IAH</li><li>• Causes include- trauma, intestinal perforation, peritonitis etc .</li><li>• trauma, intestinal perforation, peritonitis etc</li><li>• In all cases of abdominal trauma in which the development of ACS in the immediate postoperative phase is considered a risk, the abdomen should be left open and managed as for damage control surgery.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The grading system for abdominal hypertension and abdominal compartment syndrome , stated that intra-abdominal pressure of 26 mm Hg corresponds to Grade 4 abdominal hypertension .</li><li>➤ grading system for abdominal hypertension and abdominal compartment syndrome</li><li>➤ intra-abdominal pressure of 26 mm Hg corresponds to Grade 4 abdominal hypertension</li><li>➤ Ref : Sabiston Textbook of Surgery 20th Edition Page 1129.</li><li>➤ Ref</li><li>➤ : Sabiston Textbook of Surgery 20th Edition Page 1129.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is not an effect of abdominal compartment syndrome?", "options": [{"label": "A", "text": "Decrease in intra-cranial pressure (ICP)", "correct": true}, {"label": "B", "text": "Increase in renal vascular resistance leading to reduced GFR and oliguria", "correct": false}, {"label": "C", "text": "Decreased venous return and thus decreased cardiac output and hypotension", "correct": false}, {"label": "D", "text": "Decrease in lung compliance", "correct": false}], "correct_answer": "A. Decrease in intra-cranial pressure (ICP)", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/screenshot-2024-03-20-102235.jpg"], "explanation": "<p><strong>Ans. A) Decrease in intra-cranial pressure (ICP)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. Abdominal compartment syndrome can lead to an increase in renal vascular resistance due to compression of the renal vasculature . This increased resistance impairs renal blood flow, leading to reduced glomerular filtration rate (GFR) and oliguria (reduced urine output). Reduced urine output is a hallmark feature of abdominal compartment syndrome-induced renal dysfunction.</li><li>• Option B.</li><li>• Abdominal compartment syndrome</li><li>• increase in renal vascular resistance due to compression of the renal vasculature</li><li>• Option C . Elevated intra-abdominal pressure in abdominal compartment syndrome can compress the inferior vena cava and other major abdominal vessels , leading to decreased venous return to the heart . This results in reduced cardiac preload and subsequently decreased cardiac output. The reduction in cardiac output can lead to hypotension, contributing to cardiovascular instability in patients with abdominal compartment syndrome.</li><li>• Option C</li><li>• Elevated intra-abdominal pressure in abdominal compartment syndrome</li><li>• compress the inferior vena cava and other major abdominal vessels</li><li>• decreased venous return to the heart</li><li>• Option D. Intra-abdominal pressure will reduce diaphragmatic excursions , thereby reducing lung compliance.</li><li>• Option D.</li><li>• Intra-abdominal pressure</li><li>• reduce diaphragmatic excursions</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 386</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Page 386</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The effects of abdominal compartment syndrome on various organ systems includes the increase in renal vascular resistance leading to reduced GFR and oliguria , decreased venous return leading to decreased cardiac output and hypotension , and raised intracranial pressure (ICP).</li><li>➤ effects of abdominal compartment syndrome</li><li>➤ organ systems includes the increase in renal vascular resistance leading to reduced GFR and oliguria</li><li>➤ decreased venous return</li><li>➤ decreased cardiac output and hypotension</li><li>➤ raised intracranial pressure</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which is the most common injury in seatbelt-induced trauma following RTA?", "options": [{"label": "A", "text": "Duodenum", "correct": false}, {"label": "B", "text": "Liver", "correct": false}, {"label": "C", "text": "Mesentery", "correct": true}, {"label": "D", "text": "Small bowel", "correct": false}], "correct_answer": "C. Mesentery", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Mesentery</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Mesentery injuries are the most common in seatbelt-induced trauma following RTAs, emphasizing the vulnerability of the mesentery to shearing forces exerted by the seatbelt and the importance of considering mesenteric injury in patients involved in RTAs with seatbelt use.</li><li>➤ Mesentery injuries</li><li>➤ most common in seatbelt-induced trauma following RTAs,</li><li>➤ emphasizing the vulnerability of the mesentery to shearing forces exerted by the seatbelt</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 275.</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 275.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In flexion-distraction type pattern of injuries, which of these is a covert injury?", "options": [{"label": "A", "text": "Duodenal rupture", "correct": true}, {"label": "B", "text": "Splenic rupture", "correct": false}, {"label": "C", "text": "Liver trauma", "correct": false}, {"label": "D", "text": "Head injury", "correct": false}], "correct_answer": "A. Duodenal rupture", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. Splenic rupture: Splenic rupture is not typically associated with flexion-distraction injuries . Instead, it is more commonly seen in blunt trauma to the abdomen , such as during motor vehicle accidents or falls, where there is direct impact or compression of the spleen against the rib cage.</li><li>• Option B. Splenic rupture:</li><li>• not typically associated with flexion-distraction injuries</li><li>• more commonly seen in blunt trauma to the abdomen</li><li>• Option C. Liver trauma: Liver trauma may occur in various types of abdominal trauma , including blunt force injuries and penetrating injuries . While it may be associated with flexion-distraction injuries in some cases, it is not specifically characteristic of this injury pattern.</li><li>• Option C. Liver trauma:</li><li>• various types of abdominal trauma</li><li>• blunt force injuries and penetrating injuries</li><li>• Option D. Head injury: Head injury can occur in flexion-distraction injuries, especially if there is associated hyperflexion of the spine followed by rapid extension . However, it is not considered a covert injury as it is typically evident on initial evaluation and may present with symptoms such as altered mental status, focal neurological deficits, or signs of concussion.</li><li>• Option D. Head injury:</li><li>• flexion-distraction injuries, especially if there is associated hyperflexion of the spine followed by rapid extension</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Duodenal rupture is a covert injury associated with flexion-distraction type patterns of injuries .</li><li>➤ Duodenal rupture</li><li>➤ covert injury associated with flexion-distraction type patterns of injuries</li><li>➤ Flexion - distraction injuries and associated trauma-</li><li>➤ Obvious features-</li><li>➤ Obvious features-</li><li>➤ Chance fracture of lumbar spine Dislocated knee Head injury</li><li>➤ Chance fracture of lumbar spine</li><li>➤ Dislocated knee</li><li>➤ Head injury</li><li>➤ Covert injuries-</li><li>➤ Covert injuries-</li><li>➤ Duodenal rupture Popliteal artery disruption Cervical spine fracture</li><li>➤ Duodenal rupture</li><li>➤ Popliteal artery disruption</li><li>➤ Cervical spine fracture</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 346</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 346</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "During an exploratory laparotomy, the surgeon performs Mattox manoeuver. Which injury was he most likely trying to visualize?", "options": [{"label": "A", "text": "Liver injury", "correct": false}, {"label": "B", "text": "Splenic injury", "correct": false}, {"label": "C", "text": "Abdominal aorta injury", "correct": true}, {"label": "D", "text": "Inferior vena cava", "correct": false}], "correct_answer": "C. Abdominal aorta injury", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture25.jpg"], "explanation": "<p><strong>Ans. C) Abdominal aorta injury</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Liver injuries are often visualized during an exploratory laparotomy through standard surgical techniques such as liver mobilization and retraction.</li><li>• Option A. Liver injuries</li><li>• visualized during an exploratory laparotomy</li><li>• standard surgical techniques</li><li>• liver mobilization and retraction.</li><li>• Option B. Splenic injuries are typically visualized through careful exploration of the left upper quadrant during a laparotomy .</li><li>• Option B. Splenic injuries</li><li>• visualized through careful exploration of the left upper quadrant during a laparotomy</li><li>• Option D. Inferior vena cava injuries are typically visualized using a different maneuver called the Cattell-Braasch maneuver , which involves right medial visceral rotation . This maneuver allows the surgeon to access and visualize the retroperitoneum and structures adjacent to the inferior vena cava.</li><li>• Option D. Inferior vena cava</li><li>• visualized using a different maneuver called the Cattell-Braasch maneuver</li><li>• right medial visceral rotation</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Mattox maneuver is used as a surgical technique to visualize and manage injuries to the abdominal aorta during exploratory laparotomy.</li><li>➤ Mattox maneuver</li><li>➤ surgical technique to visualize and manage injuries to the abdominal aorta during exploratory laparotomy.</li><li>➤ Mattox manoeuver is left medial visceral rotation to visualise abdominal aortic injury. To visualise inferior vena cava, Cattell Braasch manoeuver is used which is right medial visceral rotation.</li><li>➤ Mattox manoeuver is left medial visceral rotation to visualise abdominal aortic injury.</li><li>➤ To visualise inferior vena cava, Cattell Braasch manoeuver is used which is right medial visceral rotation.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient was wheeled into the ER after meeting with an RTA. His parameters are BP- 90/60 mm Hg, Pulse- 112/min. After primary survey, a FAST was performed on the patient to check for signs of abdominal organ trauma. Which is the correct sequence of evaluation in this technique? Perisplenic region Perihepatic region Pericardial sac Pelvis", "options": [{"label": "A", "text": "a b c d", "correct": false}, {"label": "B", "text": "b a c d", "correct": false}, {"label": "C", "text": "c a b d", "correct": false}, {"label": "D", "text": "c b a d", "correct": true}], "correct_answer": "D. c b a d", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture26.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture27.jpg"], "explanation": "<p><strong>Ans. D) c b a d</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Focused Assessment with Sonography for Trauma (FAST) is a rapid bedside ultrasound examination used to assess for free fluid in the abdomen and pericardium , aiding in the diagnosis of traumatic injuries such as hemoperitoneum and hemopericardium. It is an essential tool in the initial evaluation of trauma patients, providing valuable information for prompt clinical decision-making.</li><li>• Focused Assessment with Sonography for Trauma</li><li>• rapid bedside ultrasound examination</li><li>• assess for free fluid in the abdomen and pericardium</li><li>• diagnosis of traumatic injuries such as hemoperitoneum and hemopericardium.</li><li>• The correct sequence of evaluation in FAST is- pericardial sac (subxiphoid) —&gt; perihepatic region (RUQ) —&gt; perisplenic region (LUQ) —&gt; Pelvis</li><li>• pericardial sac</li><li>• perihepatic region</li><li>• perisplenic region</li><li>• Pelvis</li><li>• Fig: A probe locations. B. FAST image of the right upper quadrant showing the liver, kidney, and free fluid.</li><li>• Fig:</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• The correct sequence of evaluation in FAST is- pericardial sac (subxiphoid) —&gt; perihepatic region (RUQ) —&gt; perisplenic region (LUQ) —&gt; Pelvis</li><li>• pericardial sac</li><li>• perihepatic region</li><li>• perisplenic region</li><li>• Pelvis</li><li>• Ref : ATLS Student Course Manual 10th Edition- Page 90</li><li>• Ref</li><li>• : ATLS Student Course Manual 10th Edition- Page 90</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Following penetrating trauma to abdomen, urinary leak from left ureter was noted? Which of these is not a technique of ureteric reconstruction?", "options": [{"label": "A", "text": "Boari flap", "correct": false}, {"label": "B", "text": "End to end anastomosis", "correct": false}, {"label": "C", "text": "Nesbitt procedure", "correct": true}, {"label": "D", "text": "Uretero-ureterostomy", "correct": false}], "correct_answer": "C. Nesbitt procedure", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Nesbitt procedure</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Boari flap: A Boari flap is a surgical technique used to reconstruct the ureter when there is a longer segment loss , particularly in the pelvic ureter . It involves mobilizing the bladder and creating a flap from its wall to lengthen and reposition the ureter, allowing for a tension-free anastomosis.</li><li>• Option A. Boari flap:</li><li>• surgical technique used to reconstruct the ureter when there is a longer segment loss</li><li>• pelvic ureter</li><li>• Option B. End to end anastomosis : End-to-end anastomosis involves directly connecting the two ends of the severed ureter to restore continuity . While it may be suitable for shorter segment losses or partial transections, it may not be feasible for cases involving major loss of ureteric length.</li><li>• Option</li><li>• B. End to end anastomosis</li><li>• connecting the two ends of the severed ureter to restore continuity</li><li>• Option D: Uretero-ureterostomy: Uretero-ureterostomy involves surgically connecting the injured ureter to the contralateral healthy ureter . This technique is particularly useful for managing major loss of ureteric length following penetrating trauma to the abdomen , providing a viable option for restoring urinary flow without the need for complex reconstructive procedures.</li><li>• Option D:</li><li>• Uretero-ureterostomy:</li><li>• surgically connecting the injured ureter to the contralateral healthy ureter</li><li>• useful for managing major loss of ureteric length following penetrating trauma to the abdomen</li><li>• viable option for restoring urinary flow</li><li>• need for complex reconstructive procedures.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In cases of partial transection of ureter , primary repair over a DJ stent may be performed . A tension-free spatulated ureteric anastomosis using fine absorbable sutures can be done for short segment loss. This is usually done in upper ureteric injuries .</li><li>➤ partial transection of ureter</li><li>➤ primary repair</li><li>➤ DJ stent may be performed</li><li>➤ tension-free spatulated ureteric anastomosis using fine absorbable sutures</li><li>➤ done for short segment loss.</li><li>➤ done in upper ureteric injuries</li><li>➤ Longer segment loss , especially in the pelvic ureter , is managed by ureteroneocystostomy with or without a Boari flap . Longer defects up to 15 cm can be repaired by mobilizing and hitching the bladder to the psoas major muscle (psoas hitch) with a Boari flap. Transureteroureterostomy (anastomosing the injured ureter to the contralateral ureter) can be an option in selected situations.</li><li>➤ Longer segment loss</li><li>➤ pelvic ureter</li><li>➤ managed by ureteroneocystostomy with or without a Boari flap</li><li>➤ Most ureteric injuries are iatrogenic and typically occur during hysterectomy .</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1479.</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1479.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "About pancreatic trauma, which of the following is true?", "options": [{"label": "A", "text": "FAST is extremely sensitive in detecting pancreatic trauma.", "correct": false}, {"label": "B", "text": "Amylase and lipase are very sensitive in pancreatic trauma.", "correct": false}, {"label": "C", "text": "Injuries of pancreas to the right of SMA are treated as conservatively as possible.", "correct": true}, {"label": "D", "text": "Whipple’s procedure is the procedure of choice in emergencies.", "correct": false}], "correct_answer": "C. Injuries of pancreas to the right of SMA are treated as conservatively as possible.", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Injuries of pancreas to the right of SMA are treated as conservatively as possible.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: FAST (Focused Assessment with Sonography for Trauma) is not sensitive in detecting pancreatic trauma due to the retroperitoneal location of the pancreas. CT scan is the main imaging modality used to accurately diagnose pancreatic injuries.</li><li>• Option A: FAST (Focused Assessment with Sonography for Trauma)</li><li>• not sensitive in detecting pancreatic trauma</li><li>• Option B: Amylase and lipase levels are not very sensitive in diagnosing pancreatic trauma . While they may be elevated in some cases of pancreatic injury , they are not reliable indicators and can be within normal limits even in the presence of significant pancreatic trauma.</li><li>• Option B: Amylase and lipase levels are not very sensitive in diagnosing pancreatic trauma</li><li>• they may be elevated in some cases of pancreatic injury</li><li>• Option D: Whipple's procedure (pancreaticoduodenectomy) is rarely indicated in emergency situations due to its high associated mortality rate . Emergency management of pancreatic trauma typically involves damage control procedures such as packing and drainage, with definitive surgery performed once the patient is stabilized.</li><li>• Option D: Whipple's procedure (pancreaticoduodenectomy)</li><li>• rarely indicated in emergency situations due to its high associated mortality rate</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Appropriate management approach for pancreatic trauma , includes the limitations of FAST in diagnosis , the insensitivity of amylase and lipase levels , the need for conservative management of injuries to the left of the superior mesenteric vessels , and the avoidance of Whipple's procedure in emergency situations.</li><li>➤ Appropriate management approach for pancreatic trauma</li><li>➤ limitations of FAST in diagnosis</li><li>➤ insensitivity of amylase and lipase levels</li><li>➤ need for conservative management of injuries to the left of the superior mesenteric vessels</li><li>➤ avoidance of Whipple's procedure</li><li>➤ The major problem in using FAST in this case is because the pancreas is a retroperitoneal organ. CT remains the mainstay of accurate diagnosis. Amylase or lipase estimation is insensitive. A Whipple ’ s procedure (pancreaticoduodenectomy) is rarely needed and should not be performed in emergency situation because of the very high associated mortality rate. A damage control procedure with packing and drainage should be performed and the patient referred for definitive surgery once stabilized.</li><li>➤ The major problem in using FAST in this case is because the pancreas is a retroperitoneal organ. CT remains the mainstay of accurate diagnosis.</li><li>➤ Amylase or lipase estimation is insensitive.</li><li>➤ A Whipple ’ s procedure (pancreaticoduodenectomy) is rarely needed and should not be performed in emergency situation because of the very high associated mortality rate. A damage control procedure with packing and drainage should be performed and the patient referred for definitive surgery once stabilized.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 381</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 381</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is incorrect about the steps of placement of a chest tube in patients with thoracic trauma?", "options": [{"label": "A", "text": "Tube inserted along lower border of upper rib", "correct": true}, {"label": "B", "text": "Directed posteriorly", "correct": false}, {"label": "C", "text": "A finger sweep must be performed prior to insertion", "correct": false}, {"label": "D", "text": "Connected to an underwater seal apparatus which acts as a one-way valve", "correct": false}], "correct_answer": "A. Tube inserted along lower border of upper rib", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/21/picture1.png", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/20/picture11.jpg"], "explanation": "<p><strong>Ans. A) Tube inserted along lower border of upper rib</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• The intercostal tube is inserted along the upper border of the lower rib in the 5th ICS in the triangle of safety. This is to prevent damage to the neurovascular bundle.</li><li>• The intercostal tube is inserted along the upper border of the lower rib in the 5th ICS in the triangle of safety. This is to prevent damage to the neurovascular bundle.</li><li>• Steps of insertion:</li><li>• Position the patient with the ipsilateral arm extended overhead and flexed at the elbow . Widely prepare and drape the lateral chest wall. Maintain all aseptic precautions. Identify the site for insertion of the chest tube in the 4th or 5th intercostal space. The insertion site should be between the anterior and midaxillary lines . Inject the site liberally with local anesthesia to include the skin, subcutaneous tissue, rib periosteum, and pleura. Make a 2- to 3-cm incision parallel to the ribs at the predetermined site, and bluntly dissect through the subcutaneous tissues just above the rib. Puncture the parietal pleura with the tip of the clamp. With a sterile gloved finger, perform a finger sweep to clear any adhesions and clots (i.e. perform a finger thoracostomy). Advance the tube into the pleural space Fig : Insertion of chest drain: (a) triangle of safety; (b) penetration of the skin, muscle and pleura; (c) blunt dissection of the parietal pleura; (d) suture placement; (e) gauging the distance of insertion; (f) digital examination along the tract into the pleural space; (g) withdrawal of central trochar and positioning of drain; (h) underwater seal chest drain bottle. Look and listen for air movement and bloody drainage; “fogging” of the chest tube expiration may also indicate the tube is in the pleural space. Connect the tube thoracostomy to an underwater seal apparatus with a collection chamber. Secure the tube to the skin with heavy, nonabsorbable suture. Apply a sterile dressing and secure it with a tape. Obtain a chest x-ray.</li><li>• Position the patient with the ipsilateral arm extended overhead and flexed at the elbow .</li><li>• ipsilateral arm extended overhead and flexed at the elbow</li><li>• Widely prepare and drape the lateral chest wall. Maintain all aseptic precautions.</li><li>• Identify the site for insertion of the chest tube in the 4th or 5th intercostal space. The insertion site should be between the anterior and midaxillary lines .</li><li>• insertion site should be between the anterior and midaxillary lines</li><li>• Inject the site liberally with local anesthesia to include the skin, subcutaneous tissue, rib periosteum, and pleura. Make a 2- to 3-cm incision parallel to the ribs at the predetermined site, and bluntly dissect through the subcutaneous tissues just above the rib.</li><li>• Puncture the parietal pleura with the tip of the clamp. With a sterile gloved finger, perform a finger sweep to clear any adhesions and clots (i.e. perform a finger thoracostomy).</li><li>• parietal pleura with the tip of the clamp.</li><li>• Advance the tube into the pleural space Fig : Insertion of chest drain: (a) triangle of safety; (b) penetration of the skin, muscle and pleura; (c) blunt dissection of the parietal pleura; (d) suture placement; (e) gauging the distance of insertion; (f) digital examination along the tract into the pleural space; (g) withdrawal of central trochar and positioning of drain; (h) underwater seal chest drain bottle.</li><li>• tube into the pleural space</li><li>• Fig</li><li>• Look and listen for air movement and bloody drainage; “fogging” of the chest tube expiration may also indicate the tube is in the pleural space.</li><li>• Look and listen for air movement and bloody drainage; “fogging” of the chest tube expiration may also indicate the tube is in the pleural space.</li><li>• “fogging” of the chest tube expiration</li><li>• Connect the tube thoracostomy to an underwater seal apparatus with a collection chamber.</li><li>• tube thoracostomy to an underwater seal apparatus</li><li>• Secure the tube to the skin with heavy, nonabsorbable suture.</li><li>• Apply a sterile dressing and secure it with a tape.</li><li>• Obtain a chest x-ray.</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• The intercostal tube is inserted along the upper border of the lower rib in the 5th ICS .</li><li>• intercostal tube is inserted along the upper border of the lower rib in the 5th ICS</li><li>• Ref : ATLS Student Manual 10th Edition Page 346</li><li>• Ref</li><li>• : ATLS Student Manual 10th Edition Page 346</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "After road traffic accident, a young male was rushed into the casualty after having sustained a high velocity trauma to his head. He has been unconscious since the injury and on getting a CT scan of his head, the following picture was seen. All of the following are true about the condition except.", "options": [{"label": "A", "text": "It is most likely an acute subdural haemorrhage", "correct": false}, {"label": "B", "text": "The source of bleeding is usually of venous origin", "correct": false}, {"label": "C", "text": "There is minimal associated underlying parenchyma injury in such cases", "correct": true}, {"label": "D", "text": "When features of raised ICP and neurological deterioration are present, it requires urgent evacuation", "correct": false}], "correct_answer": "C. There is minimal associated underlying parenchyma injury in such cases", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/picture8_BeeExn1.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/19/picture9_8swMt4x.jpg"], "explanation": "<p><strong>Ans. C) There is minimal associated underlying parenchyma injury in such cases</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: It is most likely an acute subdural haemorrhage. Acute subdural hemorrhage (SDH) appears on CT as a crescent-shaped, concave-convex hyperdensity that crosses suture lines but does not cross the midline because of the dural attachment at the falx cerebri . In high-velocity head trauma, acute SDH is a common finding due to the tearing of bridging veins. The patient's unconscious state since the injury and the CT appearance are consistent with acute SDH.</li><li>• Option A: It is most likely an acute subdural haemorrhage.</li><li>• Acute subdural hemorrhage</li><li>• CT as a crescent-shaped, concave-convex hyperdensity</li><li>• crosses suture lines but does not cross the midline</li><li>• dural attachment at the falx cerebri</li><li>• Option B: The source of bleeding is mostly venous The source of bleeding in acute SDH is usually venous , originating from the tearing of cortical bridging veins due to acceleration-deceleration forces during trauma. Arterial sources are less common in acute SDH compared to extradural hemorrhages.</li><li>• Option B: The source of bleeding is mostly venous</li><li>• source of bleeding in acute SDH is usually venous</li><li>• originating from the tearing of cortical bridging veins</li><li>• Option D: When features of raised ICP and neurological deterioration are present, it requires urgent evacuation. Increased intracranial pressure (ICP) and neurological deterioration are indications for urgent surgical intervention , typically a craniotomy, to evacuate the SDH. This reduces the pressure on the brain and can improve outcomes.</li><li>• Option D: When features of raised ICP and neurological deterioration are present, it requires urgent evacuation.</li><li>• Increased intracranial pressure</li><li>• neurological deterioration</li><li>• indications for urgent surgical intervention</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Acute subdural hemorrhage , a common result of high-velocity head trauma , presents with a crescent-shaped hyper-density on CT scan , usually involves significant underlying brain injury , and when accompanied by raised ICP and neurological decline, requires immediate neurosurgical evacuation.</li><li>➤ Acute subdural hemorrhage</li><li>➤ common result of high-velocity head trauma</li><li>➤ crescent-shaped hyper-density on CT scan</li><li>➤ underlying brain injury</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 366-367</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 366-367</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}]; if (!Array.isArray(questions) || questions.length === 0) { throw new Error("Questions data is empty or invalid"); } debugLog(`Successfully parsed ${questions.length} questions`); } catch (e) { console.error("Failed to parse questions_json:", e); document.getElementById('error-message').innerHTML = "Error loading quiz data. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('start-test').disabled = true; // Fallback to sample questions for testing questions = [ { text: "What is 2 + 2?", options: [ { label: "A", text: "3", correct: false }, { label: "B", text: "4", correct: true }, { label: "C", text: "5", correct: false }, { label: "D", text: "6", correct: false } ], correct_answer: "B. 4", question_images: [], explanation_images: [], explanation: "<p>2 + 2 = 4</p><p>@dams_new_robot</p>", bot: "@dams_new_robot", audio: "", video: "" } ]; debugLog("Loaded fallback questions"); } // Quiz state let currentQuestion = 0; let answers = new Array(questions.length).fill(null); let markedForReview = new Array(questions.length).fill(false); let timeRemaining = 85 * 60; // Duration in seconds let timerInterval = null; const quizId = `{title.replace(/\s+/g, '_').toLowerCase()}`; // Unique ID for local storage // Load saved progress function loadProgress() { try { debugLog("Loading progress from localStorage"); const saved = localStorage.getItem(`quiz_${quizId}`); if (saved) { const { savedAnswers, savedMarked, savedTime } = JSON.parse(saved); answers = savedAnswers || answers; markedForReview = savedMarked || markedForReview; timeRemaining = savedTime !== undefined ? savedTime : timeRemaining; debugLog("Progress loaded successfully"); } else { debugLog("No saved progress found"); } } catch (e) { console.error("Error loading progress:", e); debugLog("Failed to load progress: " + e.message); } } // Save progress function saveProgress() { try { debugLog("Saving progress to localStorage"); localStorage.setItem(`quiz_${quizId}`, JSON.stringify({ savedAnswers: answers, savedMarked: markedForReview, savedTime: timeRemaining })); debugLog("Progress saved successfully"); } catch (e) { console.error("Error saving progress:", e); debugLog("Failed to save progress: " + e.message); } } // Initialize quiz function initQuiz() { try { debugLog("Initializing quiz"); loadProgress(); const startButton = document.getElementById('start-test'); if (!startButton) { throw new Error("Start test button not found"); } startButton.addEventListener('click', startQuiz); debugLog("Start test button listener attached"); document.getElementById('previous-btn').addEventListener('click', showPreviousQuestion); document.getElementById('next-btn').addEventListener('click', showNextQuestion); document.getElementById('mark-review').addEventListener('click', toggleMarkForReview); document.getElementById('nav-toggle').addEventListener('click', toggleNavPanel); document.getElementById('submit-test').addEventListener('click', showSubmitModal); document.getElementById('continue-test').addEventListener('click', closeExitModal); document.getElementById('exit-test').addEventListener('click', () => { debugLog("Exiting test"); localStorage.removeItem(`quiz_${quizId}`); window.location.reload(); }); document.getElementById('cancel-submit').addEventListener('click', closeSubmitModal); document.getElementById('confirm-submit').addEventListener('click', submitTest); document.getElementById('take-again').addEventListener('click', () => { debugLog("Restarting test"); localStorage.removeItem(`quiz_${quizId}`); window.location.reload(); }); document.getElementById('review-test').addEventListener('click', () => showResults(currentResultQuestion)); document.getElementById('close-nav').addEventListener('click', toggleNavPanel); document.getElementById('theme-toggle').addEventListener('click', toggleTheme); document.getElementById('nav-filter').addEventListener('change', updateNavPanel); document.getElementById('prev-result').addEventListener('click', showPreviousResult); document.getElementById('next-result').addEventListener('click', showNextResult); document.getElementById('results-nav-toggle').addEventListener('click', toggleResultsNavPanel); document.getElementById('close-results-nav').addEventListener('click', toggleResultsNavPanel); document.getElementById('results-nav-filter').addEventListener('change', updateResultsNavPanel); debugLog("Quiz initialized successfully"); } catch (e) { console.error("Failed to initialize quiz:", e); debugLog("Failed to initialize quiz: " + e.message); document.getElementById('error-message').innerHTML = "Error initializing quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('start-test').disabled = true; } } // Start quiz function startQuiz() { try { debugLog("Starting quiz"); document.getElementById('instructions').classList.add('hidden'); document.getElementById('quiz').classList.remove('hidden'); showQuestion(currentQuestion); startTimer(); updateNavPanel(); debugLog("Quiz started successfully"); } catch (e) { console.error("Error starting quiz:", e); debugLog("Failed to start quiz: " + e.message); document.getElementById('error-message').innerHTML = "Error starting quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('quiz').classList.add('hidden'); document.getElementById('instructions').classList.remove('hidden'); } } // Show question function showQuestion(index) { try { debugLog(`Showing question ${index + 1}`); currentQuestion = index; const q = questions[index]; if (!q) { throw new Error(`Question ${index} is undefined`); } document.getElementById('question-number').innerHTML = `Question <span>${index + 1}</span> of ${questions.length}`; document.getElementById('question-text').innerHTML = q.text || "No question text available"; const imagesDiv = document.getElementById('question-images'); imagesDiv.innerHTML = q.question_images && q.question_images.length > 0 ? q.question_images.map(url => `<img src="${url}" alt="Question Image" class="max-w-full h-auto rounded-lg">`).join('') : ''; const optionsDiv = document.getElementById('options'); optionsDiv.innerHTML = q.options && q.options.length > 0 ? q.options.map(opt => ` <button class="option-btn w-full text-left p-3 border rounded-lg ${answers[index] === opt.label ? 'selected' : ''}" onclick="selectOption(${index}, '${opt.label}')" aria-label="Option ${opt.label}: ${opt.text}"> ${opt.label}. ${opt.text} </button> `).join('') : '<p class="text-red-500">No options available</p>'; document.getElementById('previous-btn').disabled = index === 0; document.getElementById('next-btn').disabled = index === questions.length - 1; document.getElementById('mark-review').classList.toggle('marked', markedForReview[index]); updateProgressBar(); saveProgress(); window.scrollTo({ top: 0, behavior: 'smooth' }); debugLog(`Question ${index + 1} displayed successfully`); } catch (e) { console.error("Error displaying question:", e); debugLog("Failed to display question: " + e.message); } } // Select option function selectOption(index, label) { try { debugLog(`Selecting option ${label} for question ${index + 1}`); answers[index] = label; const optionsDiv = document.getElementById('options'); const optionButtons = optionsDiv.querySelectorAll('.option-btn'); optionButtons.forEach(btn => { const btnLabel = btn.textContent.trim().split('.')[0]; btn.classList.toggle('selected', btnLabel === label); }); updateNavPanel(); saveProgress(); debugLog(`Option ${label} selected for question ${index + 1}`); } catch (e) { console.error("Error selecting option:", e); debugLog("Failed to select option: " + e.message); } } // Toggle mark for review function toggleMarkForReview() { try { debugLog(`Toggling mark for review on question ${currentQuestion + 1}`); markedForReview[currentQuestion] = !markedForReview[currentQuestion]; document.getElementById('mark-review').classList.toggle('marked', markedForReview[currentQuestion]); updateNavPanel(); saveProgress(); debugLog(`Mark for review toggled for question ${currentQuestion + 1}`); } catch (e) { console.error("Error marking for review:", e); debugLog("Failed to mark for review: " + e.message); } } // Navigate to previous question function showPreviousQuestion() { try { debugLog(`Navigating to previous question from ${currentQuestion + 1}`); if (currentQuestion > 0) { currentQuestion--; showQuestion(currentQuestion); } } catch (e) { console.error("Error navigating to previous question:", e); debugLog("Failed to navigate to previous question: " + e.message); } } // Navigate to next question function showNextQuestion() { try { debugLog(`Navigating to next question from ${currentQuestion + 1}`); if (currentQuestion < questions.length - 1) { currentQuestion++; showQuestion(currentQuestion); } } catch (e) { console.error("Error navigating to next question:", e); debugLog("Failed to navigate to next question: " + e.message); } } // Handle question navigation click function handleQuestionNavClick(index) { try { debugLog(`Navigating to question ${index + 1} via nav panel`); showQuestion(index); toggleNavPanel(); } catch (e) { console.error("Error handling navigation click:", e); debugLog("Failed to navigate via nav panel: " + e.message); } } // Start timer function startTimer() { try { debugLog("Starting timer"); timerInterval = setInterval(() => { if (timeRemaining <= 0) { debugLog("Timer expired, submitting test"); clearInterval(timerInterval); submitTest(); } else { timeRemaining--; const minutes = Math.floor(timeRemaining / 60); const seconds = timeRemaining % 60; document.getElementById('timer').innerHTML = `Time Remaining: <span>${minutes.toString().padStart(2, '0')}:${seconds.toString().padStart(2, '0')}</span>`; saveProgress(); } }, 1000); debugLog("Timer started successfully"); } catch (e) { console.error("Error starting timer:", e); debugLog("Failed to start timer: " + e.message); } } // Update progress bar function updateProgressBar() { try { debugLog("Updating progress bar"); const progress = ((currentQuestion + 1) / questions.length) * 100; document.getElementById('progress-bar').style.width = `${progress}%`; debugLog("Progress bar updated"); } catch (e) { console.error("Error updating progress bar:", e); debugLog("Failed to update progress bar: " + e.message); } } // Update quiz navigation panel function updateNavPanel() { try { debugLog("Updating quiz navigation panel"); const filter = document.getElementById('nav-filter').value; const navGrid = document.getElementById('nav-grid'); navGrid.innerHTML = questions.map((_, i) => { if (filter === 'answered' && !answers[i]) return ''; if (filter === 'unanswered' && answers[i]) return ''; if (filter === 'marked' && !markedForReview[i]) return ''; return ` <button class="question-nav-btn ${answers[i] ? 'answered' : 'unanswered'} ${markedForReview[i] ? 'marked-nav' : ''}" onclick="handleQuestionNavClick(${i})" aria-label="Go to Question ${i + 1}"> ${i + 1} </button> `; }).join(''); debugLog("Quiz navigation panel updated"); } catch (e) { console.error("Error updating quiz navigation panel:", e); debugLog("Failed to update quiz navigation panel: " + e.message); } } // Update results navigation panel function updateResultsNavPanel() { try { debugLog("Updating results navigation panel"); const filter = document.getElementById('results-nav-filter').value; const navGrid = document.getElementById('results-nav-grid'); navGrid.innerHTML = questions.map((_, i) => { if (filter === 'answered' && !answers[i]) return ''; if (filter === 'unanswered' && answers[i]) return ''; if (filter === 'marked' && !markedForReview[i]) return ''; return ` <button class="result-nav-btn-grid ${answers[i] ? 'answered' : 'unanswered'} ${markedForReview[i] ? 'marked-nav' : ''}" onclick="handleResultNavClick(${i})" aria-label="Go to Result for Question ${i + 1}"> ${i + 1} </button> `; }).join(''); debugLog("Results navigation panel updated"); } catch (e) { console.error("Error updating results navigation panel:", e); debugLog("Failed to update results navigation panel: " + e.message); } } // Toggle quiz navigation panel function toggleNavPanel() { try { debugLog("Toggling quiz navigation panel"); const navPanel = document.getElementById('nav-panel'); navPanel.classList.toggle('hidden'); debugLog("Quiz navigation panel toggled"); } catch (e) { console.error("Error toggling quiz navigation panel:", e); debugLog("Failed to toggle quiz navigation panel: " + e.message); } } // Toggle results navigation panel function toggleResultsNavPanel() { try { debugLog("Toggling results navigation panel"); const resultsNavPanel = document.getElementById('results-nav-panel'); resultsNavPanel.classList.toggle('hidden'); if (!resultsNavPanel.classList.contains('hidden')) { updateResultsNavPanel(); } debugLog("Results navigation panel toggled"); } catch (e) { console.error("Error toggling results navigation panel:", e); debugLog("Failed to toggle results navigation panel: " + e.message); } } // Handle result navigation click function handleResultNavClick(index) { try { debugLog(`Navigating to result for question ${index + 1} via nav panel`); showResults(index); toggleResultsNavPanel(); } catch (e) { console.error("Error handling result navigation click:", e); debugLog("Failed to navigate to result: " + e.message); } } // Show submit modal function showSubmitModal() { try { debugLog("Showing submit modal"); const attempted = answers.filter(a => a !== null).length; document.getElementById('attempted-count').textContent = attempted; document.getElementById('unattempted-count').textContent = questions.length - attempted; document.getElementById('submit-modal').classList.remove('hidden'); debugLog("Submit modal displayed"); } catch (e) { console.error("Error showing submit modal:", e); debugLog("Failed to show submit modal: " + e.message); } } // Close submit modal function closeSubmitModal() { try { debugLog("Closing submit modal"); document.getElementById('submit-modal').classList.add('hidden'); debugLog("Submit modal closed"); } catch (e) { console.error("Error closing submit modal:", e); debugLog("Failed to close submit modal: " + e.message); } } // Close exit modal function closeExitModal() { try { debugLog("Closing exit modal"); document.getElementById('exit-modal').classList.add('hidden'); debugLog("Exit modal closed"); } catch (e) { console.error("Error closing exit modal:", e); debugLog("Failed to close exit modal: " + e.message); } } // Submit test function submitTest() { try { debugLog("Submitting test"); clearInterval(timerInterval); document.getElementById('quiz').classList.add('hidden'); document.getElementById('submit-modal').classList.add('hidden'); document.getElementById('results').classList.remove('hidden'); showResults(0); // Start with first question // Trigger confetti animation confetti({ particleCount: 100, spread: 70, origin: { y: 0.6 } }); localStorage.removeItem(`quiz_${quizId}`); debugLog("Test submitted successfully"); } catch (e) { console.error("Error submitting test:", e); debugLog("Failed to submit test: " + e.message); } } // Show result for a single question function showResults(index) { try { debugLog(`Showing result for question ${index + 1}`); currentResultQuestion = index; let correct = 0, wrong = 0, unanswered = 0, marked = 0; answers.forEach((answer, i) => { const isCorrect = answer && questions[i].options.find(opt => opt.label === answer)?.correct; if (answer === null) unanswered++; else if (isCorrect) correct++; else wrong++; if (markedForReview[i]) marked++; }); const q = questions[index]; if (!q) { throw new Error(`Question ${index} is undefined`); } const userAnswer = answers[index]; const isCorrect = userAnswer && q.options.find(opt => opt.label === userAnswer)?.correct; const resultsContent = document.getElementById('results-content'); resultsContent.innerHTML = ` <div class="border p-4 rounded-lg ${isCorrect ? 'bg-green-50' : userAnswer ? 'bg-red-50' : 'bg-gray-50'}"> <p class="font-semibold">Question ${index + 1}: ${q.text || 'No question text'}</p> ${q.question_images && q.question_images.length > 0 ? q.question_images.map(url => `<img src="${url}" alt="Question Image" class="max-w-full h-auto rounded-lg my-2">`).join('') : ''} <p><strong>Your Answer:</strong> ${userAnswer ? `${userAnswer}. ${q.options.find(opt => opt.label === userAnswer)?.text || 'Invalid option'}` : 'Unanswered'}</p> <p><strong>Correct Answer:</strong> ${q.correct_answer || 'Unknown'}</p> <div class="mt-2">${q.explanation || 'No explanation available'}</div> ${q.explanation_images && q.explanation_images.length > 0 ? q.explanation_images.map(url => `<img src="${url}" alt="Explanation Image" class="max-w-full h-auto rounded-lg my-2">`).join('') : ''} ${q.video ? ` <button class="play-video bg-blue-500 text-white px-4 py-2 rounded-lg mt-2" onclick="loadVideo(this, '${q.video}', 'video-${index}')" aria-label="Play explanation video for Question ${index + 1}"> Play Video Explanation </button> <div id="video-${index}" class="video-container mt-2"></div> ` : '<p class="text-gray-500 mt-2">No video available</p>'} ${q.audio ? ` <button class="play-audio bg-blue-500 text-white px-4 py-2 rounded-lg mt-2" onclick="loadAudio(this, '${q.audio}', 'audio-${index}')" aria-label="Play audio explanation for Question ${index + 1}"> Play Audio Explanation </button> <div id="audio-${index}" class="audio-container mt-2"></div> ` : ''} </div> `; document.getElementById('correct-count').textContent = correct; document.getElementById('wrong-count').textContent = wrong; document.getElementById('unanswered-count').textContent = unanswered; document.getElementById('marked-count').textContent = marked; document.getElementById('result-question-number').innerHTML = `Question <span>${index + 1}</span> of ${questions.length}`; document.getElementById('prev-result').disabled = index === 0; document.getElementById('next-result').disabled = index === questions.length - 1; updateResultsNavPanel(); window.scrollTo({ top: 0, behavior: 'smooth' }); debugLog(`Result for question ${index + 1} displayed successfully`); } catch (e) { console.error("Error displaying result:", e); debugLog("Failed to display result: " + e.message); } } // Navigate to previous result function showPreviousResult() { try { debugLog(`Navigating to previous result from question ${currentResultQuestion + 1}`); if (currentResultQuestion > 0) { showResults(currentResultQuestion - 1); } } catch (e) { console.error("Error navigating to previous result:", e); debugLog("Failed to navigate to previous result: " + e.message); } } // Navigate to next result function showNextResult() { try { debugLog(`Navigating to next result from question ${currentResultQuestion + 1}`); if (currentResultQuestion < questions.length - 1) { showResults(currentResultQuestion + 1); } } catch (e) { console.error("Error navigating to next result:", e); debugLog("Failed to navigate to next result: " + e.message); } } // Lazy-load video function loadVideo(button, videoUrl, containerId) { try { debugLog(`Loading video for ${containerId}: ${videoUrl}`); if (!videoUrl) { const container = document.getElementById(containerId); container.innerHTML = `<p class="text-gray-500">No video available</p>`; button.remove(); debugLog("No video URL provided"); return; } const container = document.getElementById(containerId); container.innerHTML = ` <div class="video-loading"></div> <video controls class="w-full max-w-[600px] rounded-lg" preload="metadata" aria-label="Video explanation"> <source src="${videoUrl}" type="${videoUrl.endsWith('.m3u8') ? 'application/x-mpegURL' : 'video/mp4'}"> Your browser does not support the video tag. </video> `; container.classList.add('active'); button.remove(); // Initialize HLS.js for .m3u8 videos const video = container.querySelector('video'); if (videoUrl.endsWith('.m3u8') && Hls.isSupported()) { const hls = new Hls(); hls.loadSource(videoUrl); hls.attachMedia(video); hls.on(Hls.Events.ERROR, (event, data) => { console.error("HLS.js error:", data); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; debugLog("HLS.js error: " + JSON.stringify(data)); }); } else if (videoUrl.endsWith('.m3u8') && video.canPlayType('application/vnd.apple.mpegurl')) { video.src = videoUrl; } // Handle video load errors video.onerror = () => { console.error("Video load error for URL:", videoUrl); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; debugLog("Video load error for URL: " + videoUrl); }; // Remove loading spinner when video is ready video.onloadedmetadata = () => { container.querySelector('.video-loading').remove(); debugLog("Video loaded successfully"); }; } catch (e) { console.error("Error loading video:", e); debugLog("Failed to load video: " + e.message); const container = document.getElementById(containerId); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; } } // Lazy-load audio function loadAudio(button, audioUrl, containerId) { try { debugLog(`Loading audio for ${containerId}: ${audioUrl}`); if (!audioUrl) { const container = document.getElementById(containerId); container.innerHTML = `<p class="text-gray-500">No audio available</p>`; button.remove(); debugLog("No audio URL provided"); return; } const container = document.getElementById(containerId); container.innerHTML = ` <audio controls class="w-full max-w-[600px]" preload="metadata" aria-label="Audio explanation"> <source src="${audioUrl}" type="audio/mpeg"> Your browser does not support the audio tag. </audio> `; container.classList.add('active'); button.remove(); // Handle audio load errors const audio = container.querySelector('audio'); audio.onerror = () => { console.error("Audio load error for URL:", audioUrl); container.innerHTML = `<p class="text-red-500">Error loading audio. <a href="${audioUrl}" target="_blank" aria-label="Open audio in new tab">Open audio</a></p>`; debugLog("Audio load error for URL: " + audioUrl); }; debugLog("Audio loaded successfully"); } catch (e) { console.error("Error loading audio:", e); debugLog("Failed to load audio: " + e.message); const container = document.getElementById(containerId); container.innerHTML = `<p class="text-red-500">Error loading audio. <a href="${audioUrl}" target="_blank" aria-label="Open audio in new tab">Open audio</a></p>`; } } // Toggle dark mode function toggleTheme() { try { debugLog("Toggling theme"); document.documentElement.classList.toggle('dark'); localStorage.setItem('theme', document.documentElement.classList.contains('dark') ? 'dark' : 'light'); debugLog("Theme toggled successfully"); } catch (e) { console.error("Error toggling theme:", e); debugLog("Failed to toggle theme: " + e.message); } } // Load theme preference function loadTheme() { try { debugLog("Loading theme preference"); const theme = localStorage.getItem('theme'); if (theme === 'dark') { document.documentElement.classList.add('dark'); } debugLog("Theme loaded successfully"); } catch (e) { console.error("Error loading theme:", e); debugLog("Failed to load theme: " + e.message); } } // Initialize on DOM content loaded window.addEventListener('DOMContentLoaded', () => { try { debugLog("DOM content loaded, initializing quiz"); loadTheme(); initQuiz(); } catch (e) { console.error("Error during DOMContentLoaded:", e); debugLog("Failed to initialize on DOMContentLoaded: " + e.message); document.getElementById('error-message').innerHTML = "Error initializing quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); } }); </script> </body> </html>" frameborder="0" width="100%" height="2000px">
<div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <h2 class="text-xl font-semibold mb-4">Instructions</h2> <h4 class="text-gray-800 text-lg font-semibold mt-6 mb-4">Test Features:</h4> <ul class="space-y-3"> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Multiple choice questions with single correct answers </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Timer-based testing for realistic exam conditions </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Mark questions for review functionality </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Comprehensive results and performance analysis </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Mobile-optimized interface for learning on-the-go </li> </ul> <div class="mt-6 flex space-x-4 button-group md:flex-row flex-col"> <button class="bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="start-test">Start Test</button> </div> <div class="error-message hidden" id="error-message"></div> </div> </section> <!-- Quiz Section --> <section class="container mx-auto px-4 md:px-6 pt-4 md:pt-6 pb-1 hidden section-transition" id="quiz"> <div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <!-- Progress Bar --> <div class="w-full bg-gray-200 rounded-full h-3 mb-4"> <div class="progress-bar h-3 rounded-full" id="progress-bar" style="width: 0%"></div> </div> <!-- Question Header --> <div class="flex flex-col md:flex-row justify-between items-center mb-4"> <h2 class="text-lg font-semibold" id="question-number">Question <span>1</span> of 4</h2> <p class="text-lg font-semibold mt-2 md:mt-0" id="timer">Time Remaining: <span>00:00</span></p> </div> <!-- Question Content --> <div class="mb-6" id="question-content"> <p class="text-gray-800 mb-4" id="question-text"></p> <div class="flex flex-wrap gap-4 mb-4" id="question-images"></div> <div class="space-y-3" id="options"></div> </div> <!-- Navigation Buttons --> <div class="flex flex-col md:flex-row justify-between items-center gap-2 md:gap-4"> <div class="flex gap-2 w-full md:w-auto"> <button class="bg-[#2c5281] text-white px-4 py-3 w-full md:w-32 h-14 rounded-lg hover:bg-[#2c5281] transition" disabled="" id="previous-btn">Previous</button> <button class="bg-[#2c5281] text-white px-4 py-3 w-full md:w-32 h-14 rounded-lg hover:bg-[#2c5281] transition" id="next-btn">Next</button> </div> <div class="flex items-center gap-2"> <button class="bg-transparent text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-100 transition flex items-center gap-1" id="mark-review"> Review <svg xmlns="http://www.w3.org/2000/svg" class="h-5 w-5" viewBox="0 0 20 20" fill="currentColor"> <path d="M10 2a1 1 0 00-1 1v14l3.293-3.293a1 1 0 011.414 0L17 17V3a1 1 0 00-1-1H10z" /> </svg> </button> <button class="bg-transparent text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-100 transition flex items-center gap-1" id="nav-toggle"> Question 🧭 </button> <button class="bg-green-500 text-white px-6 py-3 w-44 h-14 rounded-lg hover:bg-green-600 transition w-full md:w-auto" id="submit-test">Submit Test</button> </div> </div> </section> <!-- Results Section --> <section class="container mx-auto px-4 md:px-6 pt-4 md:pt-6 pb-1 hidden section-transition" id="results"> <div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <h2 class="text-2xl font-semibold mb-4">Anaesthesia Machine - Results</h2> <div class="grid grid-cols-1 md:grid-cols-2 gap-4 mb-6"> <p><strong>Correct:</strong> <span id="correct-count" class="text-[#000000]">0</span></p> <p><strong>Wrong:</strong> <span id="wrong-count" class="text-[#000000]">0</span></p> <p><strong>Unanswered:</strong> <span id="unanswered-count" class="text-[#000000]-500">0</span></p> <p><strong>Marked for Review:</strong> <span id="marked-count" class="text-[#000000]">0</span></p> </div> <h3 class="text-lg font-semibold mb-4" id="result-question-number">Question <span>1</span> of 4</h3> <div class="space-y-6" id="results-content"></div> <div class="result-nav"> <button aria-label="Previous question result" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" disabled="" id="prev-result">Previous</button> <button aria-label="Toggle results navigation panel" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="results-nav-toggle">Result 🧭</button> <button aria-label="Next question result" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="next-result">Next</button> </div> <div class="mt-6 flex space-x-4 button-group md:flex-row flex-col"> <button class="bg-green-500 text-white px-6 py-2 rounded-lg hover:bg-green-600 transition" id="take-again">Take Again</button> </div> </div> </section> <!-- Exit Confirmation Modal --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 hidden" id="exit-modal" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white rounded-lg p-6 max-w-sm w-full"> <h2 class="text-xl font-semibold mb-4">Leave Test?</h2> <p class="text-gray-700 mb-4">Your progress will be lost if you leave this page. Are you sure you want to exit?</p> <div class="flex justify-end space-x-4"> <button class="bg-gray-300 text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-400 transition" id="continue-test">No, Continue</button> <button class="bg-red-500 text-white px-4 py-2 rounded-lg hover:bg-red-600 transition" id="exit-test">Yes, Exit</button> </div> </div> </div> <!-- Submit Confirmation Modal --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 hidden" id="submit-modal" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white rounded-lg p-6 max-w-sm w-full"> <h2 class="text-xl font-semibold mb-4">Confirm Submission</h2> <p class="text-gray-700 mb-2">You have attempted <span id="attempted-count">0</span> of 4 questions.</p> <p class="text-gray-700 mb-4"><span id="unattempted-count">0</span> questions are unattempted.</p> <div class="flex justify-end space-x-4"> <button class="bg-gray-300 text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-400 transition" id="cancel-submit">Cancel</button> <button class="text-white px-4 py-2 rounded-lg hover:bg-[#1a365d] transition" style="background-color: #2c5281;" id="confirm-submit">Submit Test</button> </div> </div> </div> <!-- Quiz Navigation Panel --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 z-50 nav-panel hidden overflow-y-auto" id="nav-panel" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white shadow-lg p-4 rounded-lg w-full max-w-2xl max-h-[80vh] overflow-y-auto"> <h2 class="text-lg font-semibold mb-4">Questions Navigation</h2> <div class="mb-4"> <select class="w-full p-2 border rounded-lg text-gray-700" id="nav-filter"> <option value="all">All Questions</option> <option value="answered">Answered</option> <option value="unanswered">Unanswered</option> <option value="marked">Marked for Review</option> </select> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-nav">Close</button> </div> </div> <!-- Results Navigation Panel --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 z-50 results-nav-panel hidden overflow-y-auto" id="results-nav-panel" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white shadow-lg p-4 rounded-lg w-full max-w-2xl max-h-[80vh] overflow-y-auto"> <h2 class="text-lg font-semibold mb-4">Results Navigation</h2> <div class="mb-4"> <select class="w-full p-2 border rounded-lg text-gray-700" id="results-nav-filter"> <option value="all">All Questions</option> <option value="answered">Answered</option> <option value="unanswered">Unanswered</option> <option value="marked">Marked for Review</option> </select> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="results-nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-results-nav">Close</button> </div> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="results-nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-results-nav">Close</button> </div> <!-- JavaScript Logic --> <script> // Enable debug mode for detailed logging const DEBUG_MODE = true; // Log debug messages function debugLog(message) { if (DEBUG_MODE) { console.log(`[DEBUG] ${message}`); } } // Initialize questions with error handling let questions = []; let currentResultQuestion = 0; // State for current question in results try { debugLog("Attempting to parse questions_json"); questions = [{"text": "Which of the following statements is true regarding the anatomy of the kidney?", "options": [{"label": "A", "text": "Right renal artery is longer than left renal artery", "correct": true}, {"label": "B", "text": "Right renal vein is longer than left renal vein", "correct": false}, {"label": "C", "text": "Left renal artery is longer than right renal artery", "correct": false}, {"label": "D", "text": "The anterior most structure at renal hilum is the renal artery", "correct": false}], "correct_answer": "A. Right renal artery is longer than left renal artery", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/09/08/whatsapp-image-2023-07-04-at-125621.jpg"], "explanation": "<p><strong>Ans. A) Right renal artery is longer than left renal artery</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: In fact, the left renal vein is longer than the right renal vein because the left renal vein has to cross the midline in front of the aorta to reach the inferior vena cava , while the right renal vein has a shorter and more direct path to the inferior vena cava.</li><li>• Option B:</li><li>• left renal vein is longer than the right renal vein</li><li>• left renal vein has to cross the midline in front of the aorta to reach the inferior vena cava</li><li>• Option C: The left renal artery is not longer than the right ; it is typically shorter because the aorta lies closer to the left kidney .</li><li>• Option C:</li><li>• left renal artery is not longer than the right</li><li>• shorter because the aorta lies closer to the left kidney</li><li>• Option D: In the typical anatomical arrangement, the most anterior structure at the renal hilum is the renal vein . The sequence from anterior to posterior is usually the renal vein, followed by the renal artery, and then the renal pelvis.</li><li>• Option D:</li><li>• most anterior structure at the renal hilum is the renal vein</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The right renal artery is longer than the left renal artery due to the relative positions of the aorta and the inferior vena cava , which necessitates a longer course for the right renal artery to reach the right kidney .</li><li>➤ right renal artery is longer than the left renal artery</li><li>➤ relative positions of the aorta</li><li>➤ inferior vena cava</li><li>➤ longer course for the right renal artery to reach the right kidney</li><li>➤ Left renal vein is longer than right renal vein (hence left kidney is preferred for donor nephrectomy) Right renal artery is longer Anterior to posterior structure of hilum: Vein → Artery → Renal Pelvis</li><li>➤ Left renal vein is longer than right renal vein (hence left kidney is preferred for donor nephrectomy)</li><li>➤ Left renal vein is longer than right renal vein (hence left kidney is preferred for donor nephrectomy)</li><li>➤ Left renal vein is longer than right renal vein</li><li>➤ Right renal artery is longer</li><li>➤ Right renal artery is longer</li><li>➤ Right renal artery is longer</li><li>➤ Anterior to posterior structure of hilum: Vein → Artery → Renal Pelvis</li><li>➤ Anterior to posterior structure of hilum: Vein → Artery → Renal Pelvis</li><li>➤ Anterior to posterior structure of hilum: Vein → Artery → Renal Pelvis</li><li>➤ Ref : Sabiston textbook of surgery 20 th edition pg 2069</li><li>➤ Ref : Sabiston textbook of surgery 20 th edition pg 2069</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Microscopic Hematuria is defined when there are more than?", "options": [{"label": "A", "text": "3-5 RBCs/hpf", "correct": true}, {"label": "B", "text": "30-50 RBCs/hpf", "correct": false}, {"label": "C", "text": "300-500 RBCs/hpf", "correct": false}, {"label": "D", "text": "3000-5000 RBCs/hpf", "correct": false}], "correct_answer": "A. 3-5 RBCs/hpf", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) 3-5 RBCs/hpf</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Microscopic hematuria is a clinical condition characterized by the presence of an abnormally high number of red blood cells in the urine that cannot be seen with the naked eye but can be detected using a microscope or a dipstick test during a urinalysis . It is typically defined as three or more red blood cells per high power field on microscopic examination of urinary sediment from at least two out of three urine samples.</li><li>• Microscopic hematuria</li><li>• characterized by the presence of an abnormally high number of red blood cells in the urine</li><li>• cannot be seen with the naked eye</li><li>• detected using a microscope or a dipstick test</li><li>• urinalysis</li><li>• three or more red blood cells per high power field</li><li>• Here are some of the conditions that can cause microscopic hematuria:</li><li>• Urinary Tract Infections (UTIs): These can cause irritation of the bladder or urethra and result in bleeding. Kidney Stones: These can breach the lining of the urinary tract as they pass through, causing bleeding. Glomerular Diseases: Conditions affecting the glomeruli, the filtering units of the kidneys, such as glomerulonephritis or IgA nephropathy, can cause blood to leak into the urine. Medications: Some drugs, like anticoagulants and anti-inflammatory medications, can induce bleeding in the urinary tract. Trauma: Blunt/penetrating renal trauma Benign Prostatic Hyperplasia (BPH): In men, an enlarged prostate can cause irritation or blockage of the urinary tract and result in bleeding. Systemic Diseases: Conditions such as sickle cell disease or systemic lupus erythematosus (SLE) can also cause hematuria.</li><li>• Urinary Tract Infections (UTIs): These can cause irritation of the bladder or urethra and result in bleeding.</li><li>• Urinary Tract Infections (UTIs):</li><li>• Kidney Stones: These can breach the lining of the urinary tract as they pass through, causing bleeding.</li><li>• Kidney Stones:</li><li>• Glomerular Diseases: Conditions affecting the glomeruli, the filtering units of the kidneys, such as glomerulonephritis or IgA nephropathy, can cause blood to leak into the urine.</li><li>• Glomerular Diseases:</li><li>• Medications: Some drugs, like anticoagulants and anti-inflammatory medications, can induce bleeding in the urinary tract.</li><li>• Medications:</li><li>• Trauma: Blunt/penetrating renal trauma</li><li>• Trauma:</li><li>• Benign Prostatic Hyperplasia (BPH): In men, an enlarged prostate can cause irritation or blockage of the urinary tract and result in bleeding.</li><li>• Benign Prostatic Hyperplasia (BPH):</li><li>• Systemic Diseases: Conditions such as sickle cell disease or systemic lupus erythematosus (SLE) can also cause hematuria.</li><li>• Systemic Diseases:</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Microscopic Hematuria - &gt; 3-5 RBCs/hpf</li><li>• Microscopic Hematuria - &gt; 3-5 RBCs/hpf</li><li>• Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1475</li><li>• Ref</li><li>• : Bailey and Love’s short practice of surgery 28 th edition pg 1475</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the imaging modality:", "options": [{"label": "A", "text": "X ray KUB", "correct": false}, {"label": "B", "text": "Intravenous urogram (IVU)", "correct": true}, {"label": "C", "text": "Retrograde pyelogram", "correct": false}, {"label": "D", "text": "Micturating cystourethrogram", "correct": false}], "correct_answer": "B. Intravenous urogram (IVU)", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_eSE2BFR.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/26/screenshot-2024-03-26-141006.png", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/26/screenshot-2024-03-26-141015.png", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/26/screenshot-2024-03-26-141028.png"], "explanation": "<p><strong>Ans. B) Intravenous urogram (IVU)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A: X-ray KUB This stands for Kidneys, Ureters, and Bladder X-ray . It's a plain radiograph typically used to assess the abdominal area for the presence of kidney stones , calcifications , or abnormal gas patterns. It doesn’t involve contrast and is often the first imaging test done for patients with suspected kidney stones.</li><li>• Option A: X-ray KUB</li><li>• stands for Kidneys, Ureters, and Bladder X-ray</li><li>• plain radiograph</li><li>• assess the abdominal area for the presence of kidney stones</li><li>• calcifications</li><li>• abnormal gas patterns.</li><li>• Option C: Retrograde Pyelogram This is a procedure where a catheter is placed via the urethra , bladder , and then into the ureter . Contrast is injected retrograde (upwards) into the ureter and kidney. This is usually done during a cystoscopy. The image doesn’t indicate this process as there is no visualization of catheter placement.</li><li>• Option C: Retrograde Pyelogram</li><li>• procedure where a catheter is placed via the urethra</li><li>• bladder</li><li>• then into the ureter</li><li>• Option D: Micturating cystourethrogram:</li><li>• Option D: Micturating cystourethrogram:</li><li>• Contrast is injected in the bladder via a catheter or intravenously , patient is asked to micturate and X ray is taken . It shows bladder and urethra with contrast.</li><li>• Contrast is injected in the bladder</li><li>• catheter</li><li>• intravenously</li><li>• micturate and X ray is taken</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Intravenous Urography (IVU) is an imaging modality that uses intravenous contrast to visualize the urinary system, including the kidneys, ureters, and bladder, on X-ray images taken at different time intervals . It is particularly useful for identifying urinary tract disorders such as obstructions, stones, and tumors.</li><li>➤ Intravenous Urography</li><li>➤ imaging modality</li><li>➤ intravenous contrast to visualize the urinary system,</li><li>➤ kidneys, ureters, and bladder, on X-ray images</li><li>➤ different time intervals</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1475</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1475</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 15-year-old girl presents with recurrent UTI underwent an IVU as shown below. What is pathology?", "options": [{"label": "A", "text": "Vesico-ureteric reflux (VUR)", "correct": false}, {"label": "B", "text": "Posterior urethral valves (PUV)", "correct": false}, {"label": "C", "text": "Ureterocele", "correct": true}, {"label": "D", "text": "Cystocele", "correct": false}], "correct_answer": "C. Ureterocele", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_bttt4UX.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Ureterocele</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: VUR (Vesicoureteral Reflux) Vesicoureteral reflux is the backward flow of urine from the bladder into the kidneys and ureters . This condition often presents in children and can be associated with recurrent UTIs . However, it is inferred from the retrograde flow of contrast (not seen here).</li><li>• Option A: VUR (Vesicoureteral Reflux)</li><li>• backward flow of urine from the bladder into the kidneys and ureters</li><li>• presents in children</li><li>• associated with recurrent UTIs</li><li>• Option B: Posterior Urethral Valves This condition is characterized by the presence of abnormal folds of tissue in the posterior urethra , which can cause obstruction and is generally found in male infants . It would not be the pathology in question for a 15-year-old girl.</li><li>• Option B: Posterior Urethral Valves</li><li>• presence of abnormal folds of tissue in the posterior urethra</li><li>• obstruction and is generally found in male infants</li><li>• Option D: Cystocele A cystocele occurs when the bladder herniates into the anterior vaginal wall due to weakness of the supporting pelvic floor muscles. It is more common in older women and typically does not present with a 'cobra head' sign on imaging.</li><li>• Option D: Cystocele</li><li>• bladder herniates into the anterior vaginal wall due to weakness of the supporting pelvic floor muscles.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The presence of a 'cobra head' sign on the IVU in a patient with recurrent UTIs is indicative of a ureterocele .</li><li>➤ 'cobra head' sign on the IVU in a patient with recurrent UTIs</li><li>➤ ureterocele</li><li>➤ Ureterocele is a cystic enlargement of the intramural ureter , which probably occurs due to atresia of the ureteral orifice. It has a female-to-male ratio of 4:1 and occurs bilaterally in 10% cases. In childhood, they usually present with infection. When large, they can obstruct the bladder neck or even the contralateral ureteric orifice. The classic feature of a ureterocele on an intravenous urogram (IVU) is the ‘cobra head’ sign. The treatment of simple ureteroceles is surgical excision with reimplantation of the ureter. Endoscopic incision of a ureterocele is the preferred treatment method for simple ureteroceles in infants and small children, but may result in subsequent ureteric reflux. A non-functioning kidney may need nephrectomy.</li><li>➤ Ureterocele is a cystic enlargement of the intramural ureter , which probably occurs due to atresia of the ureteral orifice.</li><li>➤ Ureterocele</li><li>➤ cystic enlargement of the intramural ureter</li><li>➤ It has a female-to-male ratio of 4:1 and occurs bilaterally in 10% cases.</li><li>➤ female-to-male ratio of 4:1</li><li>➤ bilaterally in 10% cases.</li><li>➤ In childhood, they usually present with infection. When large, they can obstruct the bladder neck or even the contralateral ureteric orifice.</li><li>➤ The classic feature of a ureterocele on an intravenous urogram (IVU) is the ‘cobra head’ sign.</li><li>➤ The treatment of simple ureteroceles is surgical excision with reimplantation of the ureter.</li><li>➤ Endoscopic incision of a ureterocele is the preferred treatment method for simple ureteroceles in infants and small children, but may result in subsequent ureteric reflux. A non-functioning kidney may need nephrectomy.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1467</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1467</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the plane that the line marked in the below picture represents:", "options": [{"label": "A", "text": "Plane of vascularity", "correct": false}, {"label": "B", "text": "Plane of trauma", "correct": false}, {"label": "C", "text": "Plane of cysts/tumours", "correct": false}, {"label": "D", "text": "Plane of avascularity", "correct": true}], "correct_answer": "D. Plane of avascularity", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture4.png"], "explanation_images": [], "explanation": "<p><strong>Ans. D) Plane of avascularity</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Plane of Vascularity This would indicate an area of the kidney that has a rich blood supply . However, the marked line is not known to represent a vascular plane, so this is not the correct choice.</li><li>• Option A: Plane of Vascularity</li><li>• area of the kidney</li><li>• rich blood supply</li><li>• Option B: Plane of Trauma There is no specific \"plane of trauma\" in renal anatomy , so this option does not apply to the marked line.</li><li>• Option B: Plane of Trauma</li><li>• no specific \"plane of trauma\" in renal anatomy</li><li>• Option C: Plane of Cysts/Tumours While cysts or tumors can occur in various places in the kidney , there isn't a specific anatomical plane that predisposes the kidney to cysts or tumors, making this option incorrect for the marked line.</li><li>• Option C: Plane of Cysts/Tumours</li><li>• occur in</li><li>• various places in the kidney</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Brodel’s line represents an avascular plane along the kidney , which is crucial for surgeons to recognize and utilize during renal surgeries to minimize blood loss and avoid damage to the kidney's vascular supply .</li><li>➤ Brodel’s line</li><li>➤ avascular plane along the kidney</li><li>➤ surgeons to recognize</li><li>➤ utilize during renal surgeries to minimize blood loss</li><li>➤ avoid damage to the kidney's vascular supply</li><li>➤ The avascular plane of Brodel is the section of renal parenchyma between 2/3 anterior and 1/3 posterior kidneys on the cross-section that is relatively avascular. The reason for its relative avascularity is that it represents the plane where the anterior and posterior segmental renal artery branches meet.</li><li>➤ The avascular plane of Brodel is the section of renal parenchyma between 2/3 anterior and 1/3 posterior kidneys on the cross-section that is relatively avascular. The reason for its relative avascularity is that it represents the plane where the anterior and posterior segmental renal artery branches meet.</li><li>➤ Ref : Online resource - https://radiopaedia.org/articles/avascular-plane-of-brodel</li><li>➤ Ref</li><li>➤ : Online resource -</li><li>➤ https://radiopaedia.org/articles/avascular-plane-of-brodel</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 23-year-old female patient presents with fever, malaise, increased frequency of urination. Urinalysis shows sterile pyuria. The image shows the following finding. Identify the correct treatment for this condition:", "options": [{"label": "A", "text": "PCNL", "correct": false}, {"label": "B", "text": "Radical nephrectomy", "correct": false}, {"label": "C", "text": "Broad spectrum antibiotics", "correct": false}, {"label": "D", "text": "Anti-Koch’s therapy", "correct": true}], "correct_answer": "D. Anti-Koch’s therapy", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_zBC9F4O.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. D) Anti-Koch’s therapy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: PCNL (Percutaneous Nephrolithotomy) This is a surgical procedure used to remove kidney stones by making a small puncture wound through the skin . It is not the appropriate treatment for renal TB, which is the underlying condition suggested by the image.</li><li>• Option A: PCNL (Percutaneous Nephrolithotomy)</li><li>• surgical procedure used to remove kidney stones by making a small puncture wound through the skin</li><li>• Option B: Radical Nephrectomy this is typically not the first line of treatment and is usually done for renal malignancies.</li><li>• Option B: Radical Nephrectomy</li><li>• not the first line of treatment</li><li>• Option C: Broad Spectrum Antibiotics While these are used to treat bacterial infections , renal TB is caused by Mycobacterium tuberculosis, which requires specific anti-tubercular treatment.</li><li>• Option C: Broad Spectrum Antibiotics</li><li>• used to treat bacterial infections</li><li>• renal TB is caused by Mycobacterium tuberculosis,</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The appropriate treatment for renal tuberculosis , indicated by a 'putty kidney' on imaging and sterile pyuria in urinalysis , is Anti-Koch’s therapy , which involves a combination of anti-tubercular drugs .</li><li>➤ appropriate treatment for renal tuberculosis</li><li>➤ 'putty kidney' on imaging</li><li>➤ sterile pyuria in urinalysis</li><li>➤ Anti-Koch’s therapy</li><li>➤ combination of anti-tubercular drugs</li><li>➤ Most common site of genitourinary TB – kidney. First site: Glomerulus (hematogenous from pulmonary focus)</li><li>➤ site of genitourinary TB – kidney.</li><li>➤ Glomerulus</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1472</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1472</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is the earliest lesion to be seen in Renal tuberculosis?", "options": [{"label": "A", "text": "Pseudo Calculi", "correct": false}, {"label": "B", "text": "Ghost calyces", "correct": false}, {"label": "C", "text": "Papillary ulcer", "correct": true}, {"label": "D", "text": "Golf hole ureter", "correct": false}], "correct_answer": "C. Papillary ulcer", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Papillary ulcer</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Pseudo Calculi Pseudo calculi can occur in renal tuberculosis but are not the earliest signs. They are a result of caseation and calcification within the renal parenchyma.</li><li>• Option A: Pseudo Calculi</li><li>• renal tuberculosis but are not the earliest signs.</li><li>• Option B: Ghost Calyces Ghost calyces refer to the calyces that appear stretched and ill-defined due to the destruction of the renal parenchyma in advanced cases of renal TB . These are not the earliest lesions but rather a later manifestation of the disease.</li><li>• Option B: Ghost Calyces</li><li>• calyces that appear stretched and ill-defined due to the destruction of the renal parenchyma in advanced cases of renal TB</li><li>• Option D: Golf Hole Ureter The \"golf hole ureter\" describes the appearance of the ureteric orifices as they become enlarged and rounded , resembling a golf hole on imaging. This is usually a later finding resulting from chronic inflammation and fibrosis.</li><li>• Option D: Golf Hole Ureter</li><li>• appearance of the ureteric orifices as they become enlarged and rounded</li><li>• golf hole on imaging.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The earliest radiological lesion observed in renal tuberculosis is the papillary ulcer . Subsequent manifestations can include ureteric involvement with Kerr’s kink , golf hole ureteral orifice , thimble bladder due to fibrosis , and caseous necrosis leading to a putty kidney.</li><li>➤ radiological lesion observed in renal tuberculosis is the papillary ulcer</li><li>➤ ureteric involvement with Kerr’s kink</li><li>➤ golf hole ureteral orifice</li><li>➤ thimble bladder due to fibrosis</li><li>➤ caseous necrosis</li><li>➤ putty kidney.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1472</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1472</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "According to the Bosniak classification of simple renal cysts the below image belongs to which class?", "options": [{"label": "A", "text": "Class I", "correct": false}, {"label": "B", "text": "Class II", "correct": true}, {"label": "C", "text": "Class IIF", "correct": false}, {"label": "D", "text": "Class III", "correct": false}], "correct_answer": "B. Class II", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/07/picture1_LNCMHHs.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_guJ6ybg.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/26/screenshot-2024-03-26-142244.png"], "explanation": "<p><strong>Ans. B) Class II</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Bosniak Category I:</li><li>• Bosniak Category I:</li><li>• Simple cysts with thin wall without septa , calcifications, or solid components . No enhancement with contrast . Benign with a virtually 0% chance of malignancy. No follow-up is necessary.</li><li>• Simple cysts with thin wall without septa , calcifications, or solid components .</li><li>• Simple cysts</li><li>• thin wall without septa</li><li>• calcifications, or solid components</li><li>• No enhancement with contrast .</li><li>• No enhancement with contrast</li><li>• Benign with a virtually 0% chance of malignancy.</li><li>• No follow-up is necessary.</li><li>• Bosniak Category II:</li><li>• Bosniak Category II:</li><li>• Minimally complicated cysts which may contain a few hairline-thin septa . Fine calcification may be present in the wall or septa . Uniformly high-attenuation lesions less than 3 cm in size that are sharply marginated and do not enhance with contrast. Considered benign with a very low risk of malignancy. Follow-up imaging may not be necessary or can be longer-term.</li><li>• Minimally complicated cysts which may contain a few hairline-thin septa .</li><li>• Minimally complicated cysts</li><li>• may contain a few hairline-thin septa</li><li>• Fine calcification may be present in the wall or septa .</li><li>• Fine calcification may be present in the wall or septa</li><li>• Uniformly high-attenuation lesions less than 3 cm in size that are sharply marginated and do not enhance with contrast.</li><li>• Considered benign with a very low risk of malignancy.</li><li>• Follow-up imaging may not be necessary or can be longer-term.</li><li>• Bosniak Category IIF:</li><li>• Bosniak Category IIF:</li><li>• More complex features than category II such as more numerous or slightly thicker septa without measurable enhancement , minimally thick calcification , and possibly perceived but not measurable enhancement of the wall or septa. \"F\" stands for \"follow-up\" as these cysts have an increased risk of malignancy and require closer imaging follow-up .</li><li>• More complex features than category II such as more numerous or slightly thicker septa without measurable enhancement , minimally thick calcification , and possibly perceived but not measurable enhancement of the wall or septa.</li><li>• More complex features than category II</li><li>• more numerous or slightly thicker septa</li><li>• without measurable enhancement</li><li>• thick calcification</li><li>• \"F\" stands for \"follow-up\" as these cysts have an increased risk of malignancy and require closer imaging follow-up .</li><li>• \"F\" stands for \"follow-up\"</li><li>• cysts have an increased risk of malignancy and require closer imaging follow-up</li><li>• Bosniak Category III:</li><li>• Bosniak Category III:</li><li>• Cysts that are indeterminate and may require surgical intervention due to their complexity. These have thickened irregular walls or septa, with measurable enhancement after contrast administration. They have an intermediate risk of malignancy (approximately 50%).</li><li>• Cysts that are indeterminate and may require surgical intervention due to their complexity.</li><li>• Cysts</li><li>• indeterminate</li><li>• may require surgical intervention</li><li>• complexity.</li><li>• These have thickened irregular walls or septa, with measurable enhancement after contrast administration.</li><li>• They have an intermediate risk of malignancy (approximately 50%).</li><li>• Bosniak Category IV:</li><li>• Bosniak Category IV:</li><li>• Cysts that clearly contain cancerous features like irregular walls or septa with definite enhancement. They often contain solid components beside any of the features of the lower categories. There is a high risk of malignancy, and these lesions often require surgical removal.</li><li>• Cysts that clearly contain cancerous features like irregular walls or septa with definite enhancement.</li><li>• Cysts that clearly contain cancerous features</li><li>• irregular walls or septa with definite enhancement.</li><li>• They often contain solid components beside any of the features of the lower categories.</li><li>• There is a high risk of malignancy, and these lesions often require surgical removal.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Ref : Schwartz principles of surgery 10 th edition page 1655</li><li>➤ Ref</li><li>➤ : Schwartz principles of surgery 10 th edition page 1655</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is the best treatment for Polycystic kidney disease?", "options": [{"label": "A", "text": "Rovsing's operation", "correct": false}, {"label": "B", "text": "Kidney transplant", "correct": true}, {"label": "C", "text": "Nephrectomy", "correct": false}, {"label": "D", "text": "Anderson Heynes dismembered pyeloplasty", "correct": false}], "correct_answer": "B. Kidney transplant", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Kidney transplant</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Rovsing's Operation This procedure involves deroofing of cysts and was traditionally used to relieve symptoms in PKD . However, it is not a definitive treatment for PKD, especially as it does not prevent the progression of the disease to end-stage renal disease (ESRD).</li><li>• Option A: Rovsing's Operation</li><li>• deroofing of cysts</li><li>• traditionally used to relieve symptoms in PKD</li><li>• Option C: Nephrectomy Nephrectomy, or surgical removal of the kidney , may be necessary in cases of severe pain, infection, or massive enlargement of the kidneys due to cysts . It is not a cure for PKD.</li><li>• Option C: Nephrectomy</li><li>• surgical removal of the kidney</li><li>• cases of severe pain, infection, or massive enlargement of the kidneys due to cysts</li><li>• Option D: Anderson-Heynes Dismembered Pyeloplasty This is a surgical procedure used to treat ureteropelvic junction (UPJ) obstruction , a condition typically unrelated to PKD. Therefore, it is not a relevant treatment for PKD.</li><li>• Option D: Anderson-Heynes Dismembered Pyeloplasty</li><li>• surgical procedure used to treat ureteropelvic junction</li><li>• obstruction</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The best treatment for Autosomal Dominant Polycystic Kidney Disease (ADPKD) when it progresses to end-stage renal disease is a kidney transplant. Other treatments like Rovsing's operation or nephrectomy may be used for symptomatic relief but do not address the underlying genetic disorder . Anderson-Heynes dismembered pyeloplasty is not a treatment for PKD as it's indicated for UPJ obstruction.</li><li>➤ best treatment for Autosomal Dominant Polycystic Kidney Disease</li><li>➤ progresses to end-stage renal disease is a kidney transplant.</li><li>➤ Rovsing's operation</li><li>➤ nephrectomy</li><li>➤ used for symptomatic relief but do not address the underlying genetic disorder</li><li>➤ ADPKD has variable penetration and approximately 50% of affected individuals eventually develop end-stage renal disease (ESRD).</li><li>➤ ADPKD has variable penetration and approximately 50% of affected individuals eventually develop end-stage renal disease</li><li>➤ ADPKD – autosomal dominant, systemic disease:</li><li>➤ ADPKD – autosomal dominant, systemic disease:</li><li>➤ Rarely manifests before the fourth decade. Hypertension, abdominal pain, haematuria or a palpable flank mass are common presentations. Control of hypertension can delay progression.</li><li>➤ Rarely manifests before the fourth decade.</li><li>➤ Hypertension, abdominal pain, haematuria or a palpable flank mass are common presentations.</li><li>➤ Control of hypertension can delay progression.</li><li>➤ Best treatment for ADPKD – Kidney transplant</li><li>➤ Best treatment for ADPKD</li><li>➤ Rovsing's surgery – Deroofing of cysts. Not done anymore.</li><li>➤ Rovsing's surgery</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1470</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1470</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old male with no significant past medical history presents for a routine health check-up. He reports no symptoms and is currently not taking any medications. Physical examination reveals the presence of several cutaneous lesions as shown in the images, including a raised, pebbly area on the lower back and a hypopigmented patch on the upper arm. An abdominal imaging study incidentally identifies a mass in the right kidney. Which of the following is the most likely diagnosis?", "options": [{"label": "A", "text": "Renal cell carcinoma", "correct": false}, {"label": "B", "text": "Retroperitoneal sarcoma", "correct": false}, {"label": "C", "text": "Angiomyolipoma", "correct": true}, {"label": "D", "text": "Malignant melanoma", "correct": false}], "correct_answer": "C. Angiomyolipoma", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/28/screenshot-2024-03-28-105134.png"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Angiomyolipoma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Renal Cell Carcinoma (RCC) RCC is a type of kidney cancer that originates in the lining of the proximal convoluted tubule. It is the most common type of kidney cancer in adults. The associated skin findings in the images are not typically seen with RCC.</li><li>• Option A: Renal Cell Carcinoma (RCC)</li><li>• type of kidney cancer that originates in the lining of the proximal convoluted tubule.</li><li>• Option B: Retroperitoneal Sarcoma</li><li>• Option B: Retroperitoneal Sarcoma</li><li>• Retroperitoneal sarcomas are a diverse group of rare tumors that arise from the retroperitoneal space. The skin findings depicted are not characteristic of retroperitoneal sarcoma.</li><li>• diverse group of rare tumors that arise from the retroperitoneal space.</li><li>• Option D: Malignant Melanoma Malignant melanoma is a type of skin cancer that can be recognized by its pigmented lesions that may vary in color and have irregular borders. The skin lesions in the images do not resemble typical melanoma. Melanoma can metastasize to the kidney, but this scenario would not explain the skin findings shown, which are indicative of TSC.</li><li>• Option D: Malignant Melanoma</li><li>• type of skin cancer that can be recognized by its pigmented lesions that may vary in color and have irregular borders.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ A patient presenting with a renal mass and specific skin lesions such as Shagreen patches and ash-leaf macules is suggestive of Tuberous Sclerosis Complex , commonly associated with renal angiomyolipoma . These patients may be asymptomatic or may present with symptoms related to the size and location of the tumor . Management may involve partial nephrectomy for symptomatic tumors, and everolimus is used as a pharmacological treatment option.</li><li>➤ renal mass and specific skin lesions such as Shagreen patches</li><li>➤ ash-leaf macules</li><li>➤ Tuberous Sclerosis Complex</li><li>➤ renal angiomyolipoma</li><li>➤ asymptomatic</li><li>➤ present with symptoms related to the size and location of the tumor</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1416</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1416</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 35-year-old male presents with acute onset of severe abdominal pain that started in the flank and now radiates to the inner thigh. On physical examination, there is marked tenderness on the right lower quadrant of the abdomen. His vital signs are stable. A non-contrast CT of the abdomen and pelvis reveals the presence of a 5mm calculus in the distal right ureter. No hydronephrosis is noted. Given the location of the stone and the patient's symptoms, which nerve is most likely responsible for the referred pain to the groin?", "options": [{"label": "A", "text": "Genitofemoral nerve", "correct": true}, {"label": "B", "text": "Iliohypogastric nerve", "correct": false}, {"label": "C", "text": "Ilioinguinal nerve", "correct": false}, {"label": "D", "text": "Subcostal nerve", "correct": false}], "correct_answer": "A. Genitofemoral nerve", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/26/screenshot-2024-03-26-150057.png", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/26/screenshot-2024-03-26-150217.png"], "explanation": "<p><strong>Ans. A) Genitofemoral nerve</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Iliohypogastric nerve The iliohypogastric nerve provides sensory innervation to the skin of the lower abdomen and upper hip . While this nerve can carry referred pain from the middle third of the ureter, it is less likely to be involved with stones in the distal ureter.</li><li>• Option B: Iliohypogastric nerve</li><li>• skin of the lower abdomen and upper hip</li><li>• Option C: Ilioinguinal nerve This nerve provides sensory innervation to the skin of the inner thigh and the root of the penis and upper scrotum in males , and the mons pubis and labia majora in females. Referred pain from the distal ureter may also be mediated by the ilioinguinal nerve, but it is typically associated with the genitofemoral nerve.</li><li>• Option C: Ilioinguinal nerve</li><li>• skin of the inner thigh and the root of the penis and upper scrotum in males</li><li>• mons pubis and labia majora in females.</li><li>• Option D: Subcostal nerve The subcostal nerve is a spinal nerve that supplies the skin and muscles of the lower anterior abdominal wall . It is more likely to carry referred pain from the upper ureter or renal pelvis, not the distal ureter.</li><li>• Option D: Subcostal nerve</li><li>• spinal nerve that supplies the skin and muscles of the lower anterior abdominal wall</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The genitofemoral nerve carries referred pain from the distal third of the ureter to the inner thigh and groin region.</li><li>➤ genitofemoral nerve carries referred pain from the distal third of the ureter to the inner thigh and groin region.</li><li>➤ Referred pain from kidney (blue shade) and ureter (red shade)</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1475, Smith’s Urology 17 th Ed. Pg 31.</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1475, Smith’s Urology 17 th Ed. Pg 31.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 65-year-old male with a history of benign prostatic hyperplasia presents to the clinic complaining of sleep disturbances for the past 2 months. He reports that he has to wake up several times at night to urinate, which is affecting his quality of life. His fluid intake is moderate, and he does not consume any fluids 2 hours before bedtime. On physical examination, his prostate is enlarged but non-tender. His laboratory tests including serum electrolytes, calcium, and glucose are within normal limits. Urinalysis shows no signs of infection or glucosuria. Nocturia implies waking up at night to pass urine at least how many times?", "options": [{"label": "A", "text": "Once", "correct": true}, {"label": "B", "text": "Twice", "correct": false}, {"label": "C", "text": "Thrice", "correct": false}, {"label": "D", "text": "Four times", "correct": false}], "correct_answer": "A. Once", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Once</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Nocturia - Increased frequency of voiding at least once a night</li><li>• Nocturia</li><li>• Increased frequency of voiding at least once a night</li><li>• The International Continence Society provides the internationally accepted definitions for symptoms relating to lower urinary tract function.</li><li>• International Continence Society</li><li>• internationally accepted definitions for symptoms relating to lower urinary tract function.</li><li>• Frequency – the patient considers that they void too often during the day. Nocturia – the individual wakes at night at least once to void. Strangury – a sensation of constantly needing to void. Typically, the patient describes having to stand/sit for long periods with the sensation that micturition is imminent. Urgency – a sudden compelling desire to pass urine that is difficult to defer.</li><li>• Frequency – the patient considers that they void too often during the day.</li><li>• Frequency</li><li>• Nocturia – the individual wakes at night at least once to void.</li><li>• Nocturia</li><li>• Strangury – a sensation of constantly needing to void. Typically, the patient describes having to stand/sit for long periods with the sensation that micturition is imminent.</li><li>• Strangury</li><li>• Urgency – a sudden compelling desire to pass urine that is difficult to defer.</li><li>• Urgency</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Nocturia is characterized by the need to wake up one or more times during the night to pass urine . It is a common symptom that can significantly impact the quality of sleep and life in affected individuals , especially in the presence of conditions like benign prostatic hyperplasia.</li><li>➤ Nocturia</li><li>➤ need to wake up one or more times during the night to pass urine</li><li>➤ impact the quality of sleep and life in affected individuals</li><li>➤ benign prostatic hyperplasia.</li><li>➤ Ref : Bailey and Love’s Short Practice of surgery 28 th edition pg 1448</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of surgery 28 th edition pg 1448</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the mismatched disease and its diagnostic test.", "options": [{"label": "A", "text": "Horse-shoe kidney: USG KUB", "correct": false}, {"label": "B", "text": "Renal cell carcinoma: Whittaker test", "correct": true}, {"label": "C", "text": "Renal TB: Early morning urinary analysis", "correct": false}, {"label": "D", "text": "Renal Cysts: CECT abdomen", "correct": false}], "correct_answer": "B. Renal cell carcinoma: Whittaker test", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Explanation:</strong></p><ul><li>• A. Horseshoe kidney is diagnosed on imaging studies like USG.</li><li>• B. Pressure measurement in the pelvicalyceal system is conducted using the Whittaker test, which involves catheterization of the renal pelvis and measurement of pressures to determine the significance of urinary tract obstruction. It is not used in renal malignancies, where imaging is diagnostic.</li><li>• C. Urine analysis in renal TB shows sterile pyuria. Urine may be subjected to CBNAAT for isolation of organism.</li><li>• D. Renal cysts or polycystic kidneys are seen on imaging like USG or CECT abdomen.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Other tests in Urology:</li><li>➤ DMSA- Renal cortical scarring in paediatric patients MAG-3 renogram/DTPA- Renal function in PUJ obstruction Urodynamic study- Catheter in bladder, measure filling/voiding pressure</li><li>➤ DMSA- Renal cortical scarring in paediatric patients</li><li>➤ MAG-3 renogram/DTPA- Renal function in PUJ obstruction</li><li>➤ Urodynamic study- Catheter in bladder, measure filling/voiding pressure</li></ul>\n<p><strong>References:</strong></p><ul><li>↳ Reference: Bailey and Love’s Short Practice of Surgery 28 th edition pages 1451-64.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 30-year-old male with no significant past medical history presents with occasional mild abdominal discomfort. He denies any urinary symptoms, such as dysuria, hematuria, or nocturia. During a routine health screening, an intravenous urogram (IVU) is performed, which reveals an abnormality. The patient's serum creatinine and blood urea nitrogen are within normal limits, and he has no history of urinary tract infections or kidney stones. Based on the IVU findings shown in the image, which of the following is the most appropriate next step in the management of this patient's condition?", "options": [{"label": "A", "text": "Rovsing's operation", "correct": false}, {"label": "B", "text": "Isthmectomy with nephropexy", "correct": false}, {"label": "C", "text": "Renal Transplant", "correct": false}, {"label": "D", "text": "Follow up", "correct": true}], "correct_answer": "D. Follow up", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/26/screenshot-2024-03-26-151128.png"], "explanation_images": [], "explanation": "<p><strong>Ans. D) Follow up</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Rovsing's operation is a surgical procedure for the deroofing of renal cysts in PCKD , not typically indicated for the condition suggested by the IVU findings, which is consistent with a horseshoe kidney.</li><li>• Option A: Rovsing's operation</li><li>• surgical procedure for the deroofing of renal cysts in PCKD</li><li>• Option B: Isthmectomy with nephropexy may be considered if the patient is planned for abdominal aortic surgeries , which is not present in this case.</li><li>• Option B: Isthmectomy</li><li>• with nephropexy</li><li>• patient is planned for abdominal aortic surgeries</li><li>• Option C: Renal Transplant is a treatment for end-stage renal disease or severely dysfunctional kidneys , which is not indicated here as the patient's renal function is normal, and the horseshoe kidney is typically a benign condition.</li><li>• Option C: Renal Transplant</li><li>• treatment for end-stage renal disease</li><li>• severely dysfunctional kidneys</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most appropriate management for an incidentally detected horseshoe kidney without associated symptoms or complications is regular monitoring of renal function and blood pressure. Surgical intervention is reserved for complications such as obstruction, infection, or significant symptomatic concerns.</li><li>➤ most appropriate management for an incidentally detected horseshoe kidney</li><li>➤ without associated symptoms or complications is regular monitoring of renal function and blood pressure.</li><li>➤ It is the most common renal fusion anomaly , occurring in about 1 in 400 live births with a male predominance. The incidence of Wilms’ tumour is higher in Horseshoe kidney.</li><li>➤ It is the most common renal fusion anomaly , occurring in about 1 in 400 live births with a male predominance. The incidence of Wilms’ tumour is higher in Horseshoe kidney.</li><li>➤ most common renal fusion anomaly</li><li>➤ 1 in 400 live births with a male predominance.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1466</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1466</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 40-year-old man is admitted with subarachnoid hemorrhage after rupture of a berry aneurysm in the brain. A CT KUB was done as he had hematuria, and it revealed the below picture. Identify the false statement about the condition:", "options": [{"label": "A", "text": "CT scan is often diagnostic of the condition", "correct": false}, {"label": "B", "text": "Most common inheritance – autosomal dominant", "correct": false}, {"label": "C", "text": "It occurs as a result of mutation in one of two genes -PKD1 on chromosome 16 and PKD2 on chromosome 4", "correct": false}, {"label": "D", "text": "Mosty manifests in first or second decade of life", "correct": true}], "correct_answer": "D. Mosty manifests in first or second decade of life", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_DBPuPS6.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. D) Mosty manifests in first or second decade of life</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: A CT scan is indeed often the imaging modality of choice for characterizing renal cysts , particularly when they are discovered incidentally.</li><li>• Option A:</li><li>• CT scan is indeed often the imaging modality of choice for characterizing renal cysts</li><li>• Option B: Autosomal dominant polycystic kidney disease (ADPKD) is more commonly seen compared to autosomal recessive type.</li><li>• Option B:</li><li>• Autosomal dominant polycystic kidney disease</li><li>• more commonly seen</li><li>• Option C: ADPKD is caused by mutations in one of two genes , either PKD1 or PKD2, which are located on chromosomes 16 and 4, respectively.</li><li>• Option C:</li><li>• ADPKD</li><li>• caused by mutations in one of two genes</li><li>• PKD1 or PKD2,</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Autosomal dominant polycystic kidney disease (ADPKD) usually does not manifest clinically until the third or fourth decades of life , and it is caused by mutations in the PKD1 or PKD2 genes . Initial imaging with a CT scan is the modality of choice to evaluate renal cysts.</li><li>➤ Autosomal dominant polycystic kidney disease</li><li>➤ does not manifest clinically until the third or fourth decades of life</li><li>➤ caused by mutations in the PKD1 or PKD2 genes</li><li>➤ ADPKD rarely manifests before the third or fourth decade of life .</li><li>➤ ADPKD</li><li>➤ rarely manifests</li><li>➤ third or fourth decade of life</li><li>➤ It occurs as a result of mutation in one of two genes (PKD1 on chromosome 16 and PKD2 on chromosome.</li><li>➤ Risk factors for the development of ESRD are:</li><li>➤ Risk factors for the development of ESRD are:</li><li>➤ Early age of presentation. HYPERTENSION. MALE sex. ADPKD gene 1. African ethnic group.</li><li>➤ Early age of presentation.</li><li>➤ Early age of presentation.</li><li>➤ HYPERTENSION.</li><li>➤ HYPERTENSION.</li><li>➤ MALE sex.</li><li>➤ MALE sex.</li><li>➤ ADPKD gene 1.</li><li>➤ ADPKD gene 1.</li><li>➤ African ethnic group.</li><li>➤ African ethnic group.</li><li>➤ ADPKD is associated with cysts in other organs , such as the liver, pancreas, arachnoid membranes, and seminal vesicles . It does not usually manifest before the age of 30 years and in some patients, it is never diagnosed.</li><li>➤ ADPKD is associated with cysts in other organs</li><li>➤ liver, pancreas, arachnoid membranes, and seminal vesicles</li><li>➤ Ref : Bailey and Love’s short practice of Surgery 28 th edition pg 1470</li><li>➤ Ref : Bailey and Love’s short practice of Surgery 28 th edition pg 1470</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 10-year-old boy with h/o recurrent urinary tract infections presents to a casualty with fever, burning micturition, and the below IVU picture. What is the probable diagnosis of the patient's condition?", "options": [{"label": "A", "text": "Ureterocele", "correct": false}, {"label": "B", "text": "Hydronephrosis", "correct": false}, {"label": "C", "text": "Horseshoe kidney", "correct": true}, {"label": "D", "text": "Vesico-ureteric reflux (VUR)", "correct": false}], "correct_answer": "C. Horseshoe kidney", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture4_MNdR4pn.png"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Horseshoe kidney</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Ureterocele: A ureterocele is a cystic dilation of the distal ureter near its entry into the bladder, often leading to obstruction . While it may present with UTIs, it does not cause the 'flower vase' sign on an IVU. It appears as “Cobra head”.</li><li>• Option A: Ureterocele:</li><li>• cystic dilation of the distal ureter near its entry into the bladder,</li><li>• obstruction</li><li>• Option B: Hydronephrosis: Hydronephrosis is due to a build-up of urine and can be secondary to various obstructive processes. It may be associated with recurrent UTIs, but the 'flower vase' sign is not characteristic of isolated hydronephrosis. It shows “Clubbing” of pelvicalyceal system.</li><li>• Option B: Hydronephrosis:</li><li>• due to a build-up of urine and can be secondary to various obstructive processes.</li><li>• It shows “Clubbing” of pelvicalyceal system.</li><li>• Option D: Vesicoureteral Reflux (VUR): VUR is the backward flow of urine from the bladder into the kidneys and can lead to recurrent UTIs. Although VUR is associated with UTIs, it does not produce the 'flower vase' sign on an IVU.</li><li>• Option D: Vesicoureteral Reflux (VUR):</li><li>• backward flow of urine from the bladder into the kidneys and can lead to recurrent UTIs.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The 'flower vase' sign on an intravenous urogram is indicative of a horseshoe kidney , a congenital malformation where the kidneys are fused at the lower poles . This condition is often asymptomatic but can be associated with complications such as urinary tract infections, stones, and hydronephrosis, which may necessitate intervention.</li><li>➤ 'flower vase' sign on an intravenous urogram</li><li>➤ horseshoe kidney</li><li>➤ congenital malformation where the kidneys are fused at the lower poles</li><li>➤ asymptomatic</li><li>➤ associated with complications such as urinary tract infections, stones, and hydronephrosis,</li><li>➤ A horseshoe kidney is a basal or basal fusion of kidneys . It forms a \"U\" shape when fused, calling it a\"horseshoe\". Commonly the kidney gets arrested in ascent at L3-L4 due to overlying inferior mesenteric artery (IMA). Horseshoe kidney is an incidental finding. Patients are often asymptomatic. If it causes symptoms, it is because of infection and stone formation. The most common symptoms associated with horseshoe kidney are renal calculi, flank pain, UTI and nausea.</li><li>➤ A horseshoe kidney is a basal or basal fusion of kidneys . It forms a \"U\" shape when fused, calling it a\"horseshoe\".</li><li>➤ horseshoe kidney</li><li>➤ basal or basal fusion of kidneys</li><li>➤ Commonly the kidney gets arrested in ascent at L3-L4 due to overlying inferior mesenteric artery (IMA).</li><li>➤ Commonly the kidney gets arrested in ascent at L3-L4 due to overlying inferior mesenteric artery</li><li>➤ Horseshoe kidney is an incidental finding. Patients are often asymptomatic. If it causes symptoms, it is because of infection and stone formation. The most common symptoms associated with horseshoe kidney are renal calculi, flank pain, UTI and nausea.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1466</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1466</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 7-year-old female with a history of recurrent urinary tract infections has been referred for further evaluation of possible renal parenchymal damage. The child's blood pressure is within normal limits, and there is no evidence of current infection or obstruction on ultrasound. To assess the renal parenchyma for scarring or structural defects, which imaging modality would be most appropriate?", "options": [{"label": "A", "text": "DMSA scan", "correct": true}, {"label": "B", "text": "DTPA scan", "correct": false}, {"label": "C", "text": "Dexa scan", "correct": false}, {"label": "D", "text": "MCU", "correct": false}], "correct_answer": "A. DMSA scan", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) DMSA scan</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: DTPA scan : A DTPA (diethylenetriaminepentaacetic acid) scan assesses renal function , particularly glomerular filtration , and is useful for evaluating perfusion and function but not specifically for scarring.</li><li>• Option B: DTPA scan</li><li>• DTPA</li><li>• scan assesses renal function</li><li>• glomerular filtration</li><li>• Option C: Dexa scan : A Dexa (dual-energy x-ray absorptiometry) scan measures bone mineral density and is not used for renal imaging.</li><li>• Option C: Dexa scan</li><li>• Dexa</li><li>• scan measures bone mineral density</li><li>• Option D: MCU (Micturating Cystourethrogram) : An MCU is a contrast x-ray study of the bladder and urethra that is performed during urination. It is the investigation of choice for vesicoureteral reflux (VUR), not renal scarring.</li><li>• Option D: MCU (Micturating Cystourethrogram)</li><li>• MCU is a contrast x-ray</li><li>• study</li><li>• bladder</li><li>• urethra</li><li>• performed during urination.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The DMSA scan is the investigation of choice for detecting renal scarring or structural defects in the kidney , particularly following recurrent urinary tract infections .</li><li>➤ DMSA scan</li><li>➤ choice for detecting renal scarring</li><li>➤ structural defects in the kidney</li><li>➤ recurrent urinary tract infections</li><li>➤ Renal scarring or structure of the Kidney is best demonstrated by a DMSA scan.</li><li>➤ Investigation of Choice</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28 th edition Pg 1459-62.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28 th edition Pg 1459-62.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the surgery shown here:", "options": [{"label": "A", "text": "Nesbitt procedure", "correct": false}, {"label": "B", "text": "Boari flap surgery", "correct": true}, {"label": "C", "text": "Young surgery", "correct": false}, {"label": "D", "text": "Weigert Meyer surgery", "correct": false}], "correct_answer": "B. Boari flap surgery", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/26/screenshot-2024-03-26-152021.png"], "explanation_images": [], "explanation": "<p><strong>Ans. B) Boari flap surgery</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Nesbitt procedure – correction of penile curvature</li><li>• Option A:</li><li>• Nesbitt procedure</li><li>• correction of penile curvature</li><li>• Option C: Young surgery – open prostatectomy</li><li>• Option C:</li><li>• Young surgery</li><li>• open prostatectomy</li><li>• Option D : Weigert Meyer surgery – not a surgery . It is a law for duplication of ureters</li><li>• Option D</li><li>• Weigert Meyer surgery</li><li>• not a surgery</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Boari flap surgery is a urological reconstructive procedure used to repair a lower ureteral defect or significant injury . It involves creating a flap from the bladder , which is then tubularized and connected to the ureter to bridge the gap and restore urinary continuity.</li><li>• Boari flap surgery</li><li>• urological reconstructive procedure</li><li>• repair a lower ureteral defect</li><li>• significant injury</li><li>• involves creating a flap from the bladder</li><li>• tubularized and connected to the ureter to bridge the gap and restore urinary continuity.</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28 th edition page 1480.</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28 th edition page 1480.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A mother was bathing her 5-year-old child and she felt a lump in the abdomen. The child has also been suffering from repeated bouts of urinary tract infections. An intravenous pyelogram shows the below picture. Identify the condition:", "options": [{"label": "A", "text": "Horseshoe kidney", "correct": true}, {"label": "B", "text": "Polycystic kidney", "correct": false}, {"label": "C", "text": "Neuroblastoma", "correct": false}, {"label": "D", "text": "Wilms tumour", "correct": false}], "correct_answer": "A. Horseshoe kidney", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/26/screenshot-2024-03-26-152617.png"], "explanation_images": [], "explanation": "<p><strong>Ans. A) Horseshoe kidney</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Polycystic Kidney Disease: Polycystic kidney disease typically presents with multiple cysts in the kidneys.</li><li>• Option B: Polycystic Kidney Disease:</li><li>• presents with multiple cysts in the kidneys.</li><li>• Option C: Neuroblastoma : Neuroblastoma is a common abdominal malignancy in children but is usually not associated with the 'flower vase' sign on IVP . It would typically present as a solid mass on imaging studies.</li><li>• Option C: Neuroblastoma</li><li>• abdominal malignancy in children but is usually not associated with the 'flower vase' sign on IVP</li><li>• Option D: Wilms Tumor: Wilms tumor is a kidney malignancy seen in children and can present with an abdominal mass . While children with horseshoe kidneys have an increased incidence of Wilms tumor, the 'flower vase' sign specifically suggests a horseshoe kidney rather than a Wilms tumor.</li><li>• Option D: Wilms Tumor:</li><li>• kidney malignancy seen in children and can present with an abdominal mass</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The 'flower vase' sign on an intravenous pyelogram is indicative of a horseshoe kidney, which is a common renal fusion anomaly and may be associated with recurrent urinary tract infections and an increased risk of renal calculi . Management typically involves treating complications as they arise.</li><li>➤ 'flower vase' sign on an intravenous pyelogram</li><li>➤ horseshoe kidney,</li><li>➤ common renal fusion anomaly</li><li>➤ recurrent urinary tract infections</li><li>➤ increased risk of renal calculi</li><li>➤ This is the most common renal fusion anomaly , occurring in about 1 in 400 live births with a male predominance. The incidence of Wilms’ tumour is higher in Horseshoe kidney. Symptoms – Usually incidental. If Symptomatic Abdominal lump in pelvis, recurrent infections and renal/ureteric stones. Treatment: Treat the complications.</li><li>➤ This is the most common renal fusion anomaly , occurring in about 1 in 400 live births with a male predominance. The incidence of Wilms’ tumour is higher in Horseshoe kidney.</li><li>➤ This is the most common renal fusion anomaly , occurring in about 1 in 400 live births with a male predominance. The incidence of Wilms’ tumour is higher in Horseshoe kidney.</li><li>➤ most common renal fusion anomaly</li><li>➤ 1 in 400 live births with a male predominance.</li><li>➤ Symptoms – Usually incidental.</li><li>➤ Symptoms – Usually incidental.</li><li>➤ If Symptomatic Abdominal lump in pelvis, recurrent infections and renal/ureteric stones.</li><li>➤ If Symptomatic Abdominal lump in pelvis, recurrent infections and renal/ureteric stones.</li><li>➤ Treatment: Treat the complications.</li><li>➤ Treatment: Treat the complications.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1466</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1466</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old diabetic patient presents with fever, burning micturition and flank pain presents to casualty. CT abdomen is ordered and the picture is given below. What could be the cause of this condition?", "options": [{"label": "A", "text": "Streptococcus", "correct": false}, {"label": "B", "text": "Staphylococcus aureus", "correct": false}, {"label": "C", "text": "E.Coli", "correct": true}, {"label": "D", "text": "Proteus mirabilis", "correct": false}], "correct_answer": "C. E.Coli", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_oX8DB2K.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) E. coli</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• This is a contrast enhanced CT abdomen that shows streaks of gas around the kidney . This is likely to be emphysematous pyelonephritis caused by Escherichia coli .</li><li>• This is a contrast enhanced CT abdomen that shows streaks of gas around the kidney . This is likely to be emphysematous pyelonephritis caused by Escherichia coli .</li><li>• enhanced CT abdomen that shows streaks of gas around the kidney</li><li>• emphysematous pyelonephritis caused by Escherichia coli</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most likely cause of emphysematous pyelonephritis, which is characterized by the presence of gas within the renal parenchyma as seen on CT in diabetic patients , is an infection with E. coli. Prompt recognition and treatment with broad-spectrum antibiotics, along with appropriate drainage, are essential for managing this potentially life-threatening condition.</li><li>➤ emphysematous pyelonephritis,</li><li>➤ presence of gas within the renal parenchyma as seen on CT in diabetic patients</li><li>➤ infection with E. coli.</li><li>➤ Common symptoms: Fever, sepsis, tenderness at the costovertebral angle known as Murphy's punch sign. Treatment- broad-spectrum antibiotics with drainage.</li><li>➤ Common symptoms: Fever, sepsis, tenderness at the costovertebral angle known as Murphy's punch sign.</li><li>➤ Treatment- broad-spectrum antibiotics with drainage.</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1471.</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th Ed. Pg 1471.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Upon microscopic examination of a urine sample, a patient is found to have the presence of characteristic crystals. Identify the type of stone, associated with this crystal found in urine analysis?", "options": [{"label": "A", "text": "Calcium carbonate stone", "correct": false}, {"label": "B", "text": "Ammonium phosphate stone", "correct": false}, {"label": "C", "text": "Uric acid", "correct": false}, {"label": "D", "text": "Calcium oxalate stone", "correct": true}], "correct_answer": "D. Calcium oxalate stone", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture4_e7X044C.png"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/26/screenshot-2024-03-26-153636.png", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/26/screenshot-2024-03-26-153434.png"], "explanation": "<p><strong>Ans. D) Calcium oxalate stone</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Calcium carbonate crystals are less commonly found in urinary sediment and do not typically have the shape shown in the image , which is suggestive of the envelope or octahedral shape characteristic of calcium oxalate stones.</li><li>• Option A: Calcium carbonate crystals</li><li>• less commonly found in urinary sediment</li><li>• do not typically have the shape shown in the image</li><li>• Option B: Ammonium phosphate stones , also known as struvite stones , tend to form in alkaline urine and usually present with a 'coffin lid' appearance under the microscope. The crystals in the image do not match this description.</li><li>• Option B: Ammonium phosphate stones</li><li>• struvite stones</li><li>• tend to form in alkaline urine</li><li>• present with a 'coffin lid' appearance</li><li>• Option C: Uric acid crystals can vary in shape , but they often appear as rhomboid or rosette-shaped under the microscope and are usually not as clearly envelope-shaped as the crystals in the image.</li><li>• Option C: Uric acid crystals</li><li>• vary in shape</li><li>• appear as rhomboid or rosette-shaped under the microscope</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The identification of envelope or octahedral-shaped crystals in a urine sample is indicative of calcium oxalate stones , which are a common type of nephrolithiasis.</li><li>➤ identification of envelope or octahedral-shaped crystals</li><li>➤ urine sample</li><li>➤ calcium oxalate stones</li><li>➤ nephrolithiasis.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1474</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1474</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 35-year-old patient presents with persistent dull flank pain and recurrent urinary tract infections. Imaging reveals a 4 cm staghorn calculus occupying a large portion of the renal collecting system. Which of the following is the most appropriate management?", "options": [{"label": "A", "text": "ESWL", "correct": false}, {"label": "B", "text": "PCNL", "correct": true}, {"label": "C", "text": "Intra renal repair surgery (RIRS)", "correct": false}, {"label": "D", "text": "Open Pyelolithotomy", "correct": false}], "correct_answer": "B. PCNL", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) PCNL</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: ESWL is a non-invasive treatment that uses shock waves to break up stones that are smaller in size , typically less than 2 cm, especially those located in the kidney or upper ureter.</li><li>• Option A: ESWL</li><li>• non-invasive treatment</li><li>• uses shock waves to break up stones</li><li>• smaller in size</li><li>• Option C: RIRS is used for stones &lt; 2 cm where ESWL is contra-indicated like pregnancy.</li><li>• Option C: RIRS</li><li>• stones &lt; 2 cm where ESWL is contra-indicated</li><li>• Option D: Open surgery was traditionally used for large renal stones but has largely been replaced by less invasive techniques like PCNL due to the higher morbidity associated with open surgery.</li><li>• Option D:</li><li>• Open surgery</li><li>• large renal stones but has largely been replaced by less invasive techniques like PCNL</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The management of choice for a patient with a 4 cm staghorn calculus is percutaneous nephrolithotomy (PCNL), which is indicated for renal stones larger than 2 cm and is particularly effective for complex stones such as staghorn calculi.</li><li>➤ management of choice for a patient with a 4 cm staghorn calculus</li><li>➤ percutaneous nephrolithotomy</li><li>➤ renal stones larger than 2 cm</li><li>➤ particularly effective for complex stones such as staghorn calculi.</li><li>➤ Indications for percutaneous nephrolithotomy</li><li>➤ Indications for percutaneous nephrolithotomy</li><li>➤ Renal stones &gt;2 cm. Lower pole renal stones Staghorn calculi Stones which are hard and resistant to ESWL like cystine.</li><li>➤ Renal stones &gt;2 cm.</li><li>➤ Lower pole renal stones</li><li>➤ Staghorn calculi</li><li>➤ Stones which are hard and resistant to ESWL like cystine.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1477</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1477</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 30-year-old male with a known history of Lesch-Nyhan syndrome presents with acute onset flank pain. A non-contrast CT of the abdomen and pelvis shows the presence of a renal stone which is not visible on the concurrent plain abdominal radiograph. Which of the following is the likely type of renal stone?", "options": [{"label": "A", "text": "Xanthine", "correct": true}, {"label": "B", "text": "Struvite", "correct": false}, {"label": "C", "text": "Phosphate", "correct": false}, {"label": "D", "text": "Oxalate", "correct": false}], "correct_answer": "A. Xanthine", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/26/screenshot-2024-03-26-154645.png"], "explanation": "<p><strong>Ans. A) Xanthine</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Struvite stones , composed of magnesium ammonium phosphate , are typically radiopaque and are associated with urinary tract infections with urease-producing bacteria, such as Proteus mirabilis.</li><li>• Option B: Struvite stones</li><li>• magnesium ammonium phosphate</li><li>• radiopaque</li><li>• Option C: Calcium phosphate stones are usually radiopaque and can be seen on plain abdominal radiographs. They are often associated with metabolic conditions, such as hyperparathyroidism.</li><li>• Option C: Calcium phosphate stones</li><li>• radiopaque</li><li>• seen on plain abdominal radiographs.</li><li>• Option D: Calcium oxalate stones are the most common type of kidney stones and are typically radiopaque on plain radiographs due to their high calcium content.</li><li>• Option D: Calcium oxalate stones</li><li>• most common type of kidney stones</li><li>• radiopaque</li><li>• plain radiographs</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Xanthine stones are a type of radiolucent renal calculus that can be associated with genetic disorders affecting purine metabolism , such as Lesch-Nyhan syndrome , and may not be visible on plain radiographs.</li><li>➤ Xanthine stones</li><li>➤ type of radiolucent renal calculus</li><li>➤ associated with genetic disorders affecting purine metabolism</li><li>➤ Lesch-Nyhan syndrome</li><li>➤ not be visible on plain radiographs.</li><li>➤ Radiolucent renal stones</li><li>➤ Radiolucent renal stones</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1474</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1474</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 35-year-old male presents to the emergency department with acute right flank pain. Ultrasound abdomen shows the right renal stone. He undergoes the following procedure. Identify the incorrect statement about the procedure.", "options": [{"label": "A", "text": "It can lead to a complication called Steinstrasse", "correct": false}, {"label": "B", "text": "Pregnancy is an absolute contraindication", "correct": false}, {"label": "C", "text": "The maximum size of stone removed is 25 mm.", "correct": true}, {"label": "D", "text": "Lower calyceal stones are not amenable to this treatment modality", "correct": false}], "correct_answer": "C. The maximum size of stone removed is 25 mm.", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_FMGapLr.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) The maximum size of stone removed by is 25 mm.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: It can lead to a complication called Steinstrasse : Steinstrasse is a German word meaning ‘street of stones’. It describes a row of closely gathered stone fragments that line the distal end of the ureter . This occurs when the stone burden is high or when the stones are hard. These stones are usually asymptomatic and pass spontaneously; however, they may cause obstruction, requiring surgical intervention.</li><li>• Option A: It can lead to a complication called Steinstrasse</li><li>• Steinstrasse is a German word</li><li>• ‘street of stones’.</li><li>• row of closely gathered stone fragments that line the distal end of the ureter</li><li>• Option B: Pregnancy is a contra-indication</li><li>• Option B: Pregnancy is a contra-indication</li><li>• Option D: Lower calyceal stones are not amenable</li><li>• Option D: Lower calyceal stones are not amenable</li><li>• Absolute contraindications of ESWL:</li><li>• Absolute contraindications of ESWL:</li><li>• Pregnancy Bleeding disorders</li><li>• Pregnancy</li><li>• Bleeding disorders</li><li>• Relative contraindications of ESWL:</li><li>• Relative contraindications of ESWL:</li><li>• Pacemaker Distal obstruction Obesity Orthopaedic abnormalities like Scoliosis and Kyphoscoliosis Uncontrolled HTN Aneurysm Renal failure</li><li>• Pacemaker</li><li>• Distal obstruction</li><li>• Obesity</li><li>• Orthopaedic abnormalities like Scoliosis and Kyphoscoliosis</li><li>• Uncontrolled HTN</li><li>• Aneurysm</li><li>• Renal failure</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• ESWL used for renal stones is best done for stones between 5 mm to 20 mm size , non-lower calyceal stones . Large stones may produce big fragments which may traumatize the ureter leading to “steinstrasse”</li><li>• ESWL used for renal stones</li><li>• stones between 5 mm to 20 mm size</li><li>• non-lower calyceal stones</li><li>• Large stones</li><li>• big fragments which may traumatize the ureter leading to “steinstrasse”</li><li>• Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1476</li><li>• Ref</li><li>• : Bailey and Love’s short practice of surgery 28 th edition pg 1476</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the procedure done in the image below:", "options": [{"label": "A", "text": "Cystoscopy", "correct": false}, {"label": "B", "text": "Catheterization", "correct": false}, {"label": "C", "text": "PCNL", "correct": true}, {"label": "D", "text": "ESWL", "correct": false}], "correct_answer": "C. PCNL", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/26/screenshot-2024-03-26-155055.png"], "explanation_images": [], "explanation": "<p><strong>Ans. C) PCNL</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Cystoscopy involves the use of a cystoscope , which is an endoscopic instrument used to visualize the interior of the bladder and the urethra. It is typically thinner and more flexible or slightly rigid than the instrument shown.</li><li>• Option A: Cystoscopy</li><li>• use of a cystoscope</li><li>• endoscopic instrument used to visualize the interior of the bladder and the urethra.</li><li>• Option B: Catheterization involves the insertion of a catheter , a thin flexible tube , into the bladder via the urethra to drain urine.</li><li>• Option B: Catheterization</li><li>• insertion of a catheter</li><li>• thin flexible tube</li><li>• bladder</li><li>• Option D: ESWL is a non-invasive procedure that uses acoustic pulse waves to break kidney stones into smaller fragments. It does not involve the use of an endoscopic instrument like the one shown.</li><li>• Option D: ESWL is a non-invasive procedure</li><li>• acoustic pulse waves to break kidney stones into smaller fragments.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The instrument depicted is a nephroscope used in percutaneous nephrolithotomy (PCNL), a minimally invasive procedure to remove kidney stones by creating a direct channel to the kidney through the skin.</li><li>➤ instrument depicted is a nephroscope used in percutaneous nephrolithotomy</li><li>➤ minimally invasive procedure</li><li>➤ remove kidney stones</li><li>➤ direct channel to the kidney through the skin.</li><li>➤ The above image is of a PCNL scope used to remove stones by a minimally invasive method.</li><li>➤ PCNL scope used to remove stones by a minimally invasive method.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition Page 1476-77</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition Page 1476-77</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 60-year-old man who recently quit smoking, presents with intermittent profuse hematuria and flank pain for 2 months. Abdominal exam shows a left flank mass which is ballotable. Investigation shows elevated serum bilirubin, alkaline phosphatase, and prolonged prothrombin time. What could be the underlying pathology?", "options": [{"label": "A", "text": "Renal cell carcinoma", "correct": true}, {"label": "B", "text": "Retroperitoneal sarcoma", "correct": false}, {"label": "C", "text": "Angiomyolipoma", "correct": false}, {"label": "D", "text": "Malignant melanoma", "correct": false}], "correct_answer": "A. Renal cell carcinoma", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Renal cell carcinoma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: While retroperitoneal sarcoma can present with flank pain and hematuria due to mass effect or invasion of the renal parenchyma , it is less commonly associated with paraneoplastic syndromes affecting the liver.</li><li>• Option B:</li><li>• retroperitoneal sarcoma</li><li>• flank pain and hematuria</li><li>• mass effect</li><li>• invasion of the renal parenchyma</li><li>• Option C: Angiomyolipoma is typically a benign renal tumor made up of blood vessels, muscle, and fat . It can cause flank pain and hematuria if it is large or bleeds , but it is not usually associated with liver dysfunction.</li><li>• Option C: Angiomyolipoma</li><li>• benign renal tumor</li><li>• blood vessels, muscle, and fat</li><li>• cause flank pain and hematuria if it is large or bleeds</li><li>• Option D: Malignant melanoma can metastasize to the kidney and cause hematuria ; however, it is less likely to cause the liver dysfunction described without evidence of hepatic metastases.</li><li>• Option D: Malignant melanoma</li><li>• metastasize to the kidney and cause hematuria</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The presence of hematuria and flank pain in a patient with a smoking history, along with evidence of non-metastatic liver dysfunction (elevated serum bilirubin, alkaline phosphatase, and prolonged prothrombin time), is highly suggestive of renal cell carcinoma , potentially with associated Stauffer syndrome.</li><li>➤ presence of hematuria and flank pain</li><li>➤ smoking history, along with evidence of non-metastatic liver dysfunction</li><li>➤ renal cell carcinoma</li><li>➤ Stauffer syndrome.</li><li>➤ Paraneoplastic syndromes associated with RCC include :</li><li>➤ Paraneoplastic syndromes associated with RCC include</li><li>➤ Elevated ESR (Most common) Stauffer syndrome - non-metastatic liver dysfunction, characterised by elevated serum bilirubin, ALP and prolonged prothrombin time Hypercalcemia - due to increased PTH related peptide Hypertension Polycythemia Cushing's syndrome Lambert Eaton syndrome</li><li>➤ Elevated ESR (Most common)</li><li>➤ Stauffer syndrome - non-metastatic liver dysfunction, characterised by elevated serum bilirubin, ALP and prolonged prothrombin time</li><li>➤ Hypercalcemia - due to increased PTH related peptide</li><li>➤ Hypertension</li><li>➤ Polycythemia</li><li>➤ Cushing's syndrome</li><li>➤ Lambert Eaton syndrome</li><li>➤ Ref : Bailey and Love’s Short Practice of surgery 28 th Edition pg 1482</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of surgery 28 th Edition pg 1482</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Radical nephrectomy typically involves resection of the following except?", "options": [{"label": "A", "text": "Gerota's fascia", "correct": false}, {"label": "B", "text": "Ipsilateral adrenal gland", "correct": false}, {"label": "C", "text": "Surrounding hilar lymph nodes", "correct": false}, {"label": "D", "text": "Entire ipsilateral ureter", "correct": true}], "correct_answer": "D. Entire ipsilateral ureter", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Entire ipsilateral ureter</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Gerota's fascia , the fibrous envelope that encloses the kidney and perirenal fat , is typically removed during a radical nephrectomy.</li><li>• Option A: Gerota's fascia</li><li>• fibrous envelope that encloses the kidney and perirenal fat</li><li>• removed during a radical nephrectomy.</li><li>• Option B: The ipsilateral adrenal gland is often removed during a radical nephrectomy, especially if the upper pole of the kidney is involved , or if the tumor is large or centrally located . However, in modern nephrectomy practices, the adrenal gland may be spared if imaging and intraoperative findings suggest no involvement.</li><li>• Option B:</li><li>• ipsilateral adrenal gland</li><li>• removed during a radical nephrectomy,</li><li>• upper pole of the kidney is involved</li><li>• tumor is large or centrally located</li><li>• Option C: The surrounding hilar lymph nodes are usually removed during a radical nephrectomy to assess for metastatic spread of renal cell carcinoma.</li><li>• Option C:</li><li>• surrounding hilar lymph nodes</li><li>• removed during a radical nephrectomy</li><li>• metastatic spread of renal cell carcinoma.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Radical nephrectomy typically involves the removal of the kidney within Gerota's fascia , the ipsilateral adrenal gland (depending on tumor characteristics and location), and surrounding hilar lymph nodes . The entire ipsilateral ureter is not routinely resected unless indicated by the presence of tumor within it or very close proximity.</li><li>➤ Radical nephrectomy</li><li>➤ removal of the kidney within Gerota's fascia</li><li>➤ ipsilateral adrenal gland</li><li>➤ surrounding hilar lymph nodes</li><li>➤ ipsilateral ureter</li><li>➤ resected</li><li>➤ unless indicated by the presence of tumor within it or very close proximity.</li><li>➤ The standard management for stage I or II renal tumours and selected cases of stage III disease is radical nephrectomy. This procedure involves en bloc removal of Gerota’s fascia and its contents, including the kidney, the ipsilateral adrenal gland, and adjacent hilar lymph Nodes.</li><li>➤ The standard management for stage I or II renal tumours and selected cases of stage III disease is radical nephrectomy.</li><li>➤ This procedure involves en bloc removal of Gerota’s fascia and its contents, including the kidney, the ipsilateral adrenal gland, and adjacent hilar lymph Nodes.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1483</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1483</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 2-year-old male child with hematuria and fever is admitted to the casualty. On examination, right side abdominal mass is felt which does not extend over the midline. A CT scan was done which showed a solid mass with cystic areas in the lower and upper quadrants arising from the right kidney. What is the most probable diagnosis?", "options": [{"label": "A", "text": "Neuroblastoma", "correct": false}, {"label": "B", "text": "Wilms tumour", "correct": true}, {"label": "C", "text": "Tuberous sclerosis", "correct": false}, {"label": "D", "text": "Angiomyolipoma", "correct": false}], "correct_answer": "B. Wilms tumour", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Wilms tumour</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Neuroblastoma is a common pediatric malignancy that typically originates in the adrenal gland or paraspinal region . It can present as an abdominal mass and occasionally involves the kidney, but it often crosses the midline and frequently shows calcifications on imaging.</li><li>• Option A: Neuroblastoma</li><li>• common pediatric malignancy</li><li>• originates in the adrenal gland or paraspinal region</li><li>• Option C: Tuberous sclerosis is a genetic disorder that may lead to the development of benign tumors in multiple organs , including the brain, skin, heart, and kidneys . While angiomyolipomas are associated with tuberous sclerosis, they are usually seen in older patients and are not commonly presented as a solid mass with cystic changes in children.</li><li>• Option C: Tuberous sclerosis</li><li>• genetic disorder</li><li>• development of benign tumors in multiple organs</li><li>• brain, skin, heart, and kidneys</li><li>• Option D: Angiomyolipomas are benign renal tumors composed of blood vessels, smooth muscle, and fat . They are seen in adults and are associated with tuberous sclerosis complex. They usually do not present with an acute abdomen or systemic symptoms like fever.</li><li>• Option D: Angiomyolipomas</li><li>• benign renal tumors composed of blood vessels, smooth muscle, and fat</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most probable diagnosis in a young child presenting with hematuria, fever, and a non-midline crossing abdominal mass , with CT imaging showing a solid mass with cystic areas in the kidney, is Wilms tumor . This tumor is the most common primary renal tumor of childhood and is typically treated with a combination of surgery and chemotherapy.</li><li>➤ hematuria, fever, and a non-midline crossing abdominal mass</li><li>➤ CT imaging showing a solid mass</li><li>➤ cystic areas in the kidney,</li><li>➤ Wilms tumor</li><li>➤ Wilms tumour:</li><li>➤ Wilms tumour:</li><li>➤ Presentation : The most common presenting feature is asymptomatic abdominal mass. Other symptoms may be hypertension, hematuria and weight loss. Most common primary renal tumours of childhood (2-5 Years) – Wilms tumour Treatment : Surgery and chemotherapy. Neuroblastoma : crosses the midline, shows calcifications on CT Angiomyolipoma : mostly seen in adults.</li><li>➤ Presentation : The most common presenting feature is asymptomatic abdominal mass. Other symptoms may be hypertension, hematuria and weight loss.</li><li>➤ Presentation</li><li>➤ Most common primary renal tumours of childhood (2-5 Years) – Wilms tumour</li><li>➤ Treatment : Surgery and chemotherapy.</li><li>➤ Treatment</li><li>➤ Neuroblastoma : crosses the midline, shows calcifications on CT</li><li>➤ Neuroblastoma</li><li>➤ Angiomyolipoma : mostly seen in adults.</li><li>➤ Angiomyolipoma</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1485</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1485</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 55-year-old male with a history of nephrolithiasis presents with severe left flank pain and nausea. Preliminary ultrasound findings suggest hydronephrosis. As his clinician, you consider further diagnostic measures. Which of the following statements about hydronephrosis is false?", "options": [{"label": "A", "text": "The least invasive technique for diagnosis is ultrasound KUB", "correct": false}, {"label": "B", "text": "Best diagnostic modality to confirm obstructive dilatation is DTPA scan", "correct": false}, {"label": "C", "text": "Retrograde pyelography confirms the site of obstruction", "correct": false}, {"label": "D", "text": "IVU can be used in functional and non-functional kidneys", "correct": true}], "correct_answer": "D. IVU can be used in functional and non-functional kidneys", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) IVU can be used in functional and non-functional kidneys</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: The least invasive initial imaging technique for diagnosing hydronephrosis is ultrasound of the kidneys, ureters, and bladder (KUB). It is non-invasive, widely available, and can quickly identify dilation of the renal pelvis and calyces.</li><li>• Option A:</li><li>• least invasive initial imaging technique</li><li>• diagnosing hydronephrosis is ultrasound of the kidneys, ureters, and bladder</li><li>• Option B: The best diagnostic modality to assess for obstructive dilation within the renal collecting system is a renal scintigraphy scan , such as a diethylene triamine pentaacetic acid (DTPA) scan. This test provides functional information about drainage and can quantitatively assess differential renal function and the presence of obstruction.</li><li>• Option B:</li><li>• assess for obstructive dilation within the renal collecting system is a renal scintigraphy scan</li><li>• diethylene triamine pentaacetic acid (DTPA) scan.</li><li>• Option C: Retrograde pyelography is an invasive procedure that involves the insertion of a scope into the urethra and bladder to visualize the ureters and collecting system . It can delineate the site and cause of an obstruction in the urinary tract.</li><li>• Option C: Retrograde pyelography</li><li>• invasive procedure that involves the insertion of a scope into the urethra</li><li>• bladder to visualize the ureters</li><li>• collecting system</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ An intravenous urogram (IVU) is not useful for non-functional kidneys because it requires the kidney to excrete contrast to visualize the urinary tract . For diagnosing hydronephrosis , ultrasound is the least invasive method , a DTPA scan is the best to confirm obstructive dilation , and retrograde pyelography can localize the site of obstruction.</li><li>➤ intravenous urogram</li><li>➤ not useful for non-functional kidneys</li><li>➤ requires the kidney to excrete contrast to visualize the urinary tract</li><li>➤ hydronephrosis</li><li>➤ ultrasound is the least invasive method</li><li>➤ DTPA scan is the best to confirm obstructive dilation</li><li>➤ IVU can be used only if the kidney is functional.</li><li>➤ IVU can be used only if the kidney is functional.</li><li>➤ Ultrasound is the least invasive technique for diagnosing hydronephrosis. Retrograde pyelography can confirm the site of obstruction. Intravenous urogram (IVU) is helpful only if the obstructed kidney is functional. Renal isotope scan (DTPA or MAG-3 ) is the best modality to confirm the obstructive dilatation of the collecting system.</li><li>➤ Ultrasound is the least invasive technique for diagnosing hydronephrosis.</li><li>➤ Retrograde pyelography can confirm the site of obstruction.</li><li>➤ Intravenous urogram (IVU) is helpful only if the obstructed kidney is functional.</li><li>➤ Renal isotope scan (DTPA or MAG-3 ) is the best modality to confirm the obstructive dilatation of the collecting system.</li><li>➤ Ref : Bailey and Love’s Short Practice of surgery 28 th edition Pg 1468-69.</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of surgery 28 th edition Pg 1468-69.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 40-year-old female presents with seizure, recurrent gross hematuria and left flank abdominal pain. Abdominal CT reveals left perinephric hematoma with 3 cm angiomyolipoma along with multiple right renal angiomyolipoma measuring 1.5 to 6.5 cm. What would be the most probable diagnosis?", "options": [{"label": "A", "text": "VHL syndrome", "correct": false}, {"label": "B", "text": "Autosomal dominant polycystic kidney disease", "correct": false}, {"label": "C", "text": "Tuberous sclerosis", "correct": true}, {"label": "D", "text": "Hereditary angiolipoma", "correct": false}], "correct_answer": "C. Tuberous sclerosis", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/26/screenshot-2024-03-26-161012.png"], "explanation": "<p><strong>Ans. C) Tuberous sclerosis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Von Hippel-Lindau (VHL) Syndrome is a hereditary cancer syndrome that leads to the development of multiple tumors and cysts in different organs . While renal cysts and clear cell carcinoma are common, multiple angiomyolipomas are not typically associated with this condition.</li><li>• Option A: Von Hippel-Lindau (VHL) Syndrome</li><li>• hereditary cancer syndrome</li><li>• leads to the development of multiple tumors</li><li>• cysts in different organs</li><li>• Option B: Autosomal Dominant Polycystic Kidney Disease (ADPKD ) is characterized by the presence of numerous cysts in both kidneys , which can lead to abdominal pain and hematuria. However, angiomyolipomas are not a hallmark of this disease.</li><li>• Option B: Autosomal Dominant Polycystic Kidney Disease (ADPKD</li><li>• presence of numerous cysts in both kidneys</li><li>• lead to abdominal pain and hematuria.</li><li>• Option D: Hereditary Leiomyomatosis and Renal Cell Cancer (HLRCC) HLRCC, previously known as hereditary angiolipoma, is associated with cutaneous leiomyomas and an increased risk of renal cell carcinoma , not angiomyolipomas.</li><li>• Option D: Hereditary Leiomyomatosis</li><li>• Renal Cell Cancer</li><li>• cutaneous leiomyomas</li><li>• increased risk of renal cell carcinoma</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The clinical presentation of seizures, recurrent gross hematuria, flank pain, and CT findings of multiple renal angiomyolipomas is most suggestive of tuberous sclerosis. This genetic disorder is associated with various benign and malignant tumors , including renal angiomyolipomas , and requires a multidisciplinary management approach.</li><li>➤ seizures, recurrent gross hematuria, flank pain, and CT findings of multiple renal angiomyolipomas</li><li>➤ tuberous sclerosis.</li><li>➤ genetic disorder</li><li>➤ various benign and malignant tumors</li><li>➤ renal angiomyolipomas</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1456</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1456</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 49-year-old male with 35 pack years of smoking presented with sudden painless swelling in the left scrotum and hematuria. On laboratory investigation, Alpha Fetoprotein and lactate dehydrogenase were negative. What is the most probable diagnosis?", "options": [{"label": "A", "text": "Epididymitis", "correct": false}, {"label": "B", "text": "Seminoma testis", "correct": false}, {"label": "C", "text": "Renal cell carcinoma", "correct": true}, {"label": "D", "text": "Carcinoma lung", "correct": false}], "correct_answer": "C. Renal cell carcinoma", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/26/screenshot-2024-03-26-161829.png"], "explanation": "<p><strong>Ans. C) Renal cell carcinoma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Epididymitis typically presents with pain and swelling in the scrotal area and is often accompanied by signs of infection or inflammation , which might include fever or an elevated white cell count, not typically associated hematuria or a scrotal mass.</li><li>• Option A: Epididymitis</li><li>• presents with pain and swelling in the scrotal area</li><li>• accompanied by signs of infection or inflammation</li><li>• Option B: Seminoma is a type of testicular cancer that may present with a painless scrotal mass ; however, it usually elevates serum LDH and may elevate AFP if there is a non-seminomatous component. Hematuria is not a feature.</li><li>• Option B: Seminoma</li><li>• testicular cancer that may present with a painless scrotal mass</li><li>• elevates serum LDH</li><li>• may elevate AFP</li><li>• Option D: A primary lung carcinoma may present with various paraneoplastic syndromes and can metastasize to the kidneys or cause a mass in the scrotum if it spreads, but this is less common compared to the presentation of RCC.</li><li>• Option D:</li><li>• primary lung carcinoma</li><li>• paraneoplastic syndromes</li><li>• can metastasize to the kidneys</li><li>• cause a mass in the scrotum</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ In a patient with a significant smoking history , presenting with a painless scrotal mass andhematuria , with normal AFP and LDH levels , the most likely diagnosis is renal cell carcinoma . This diagnosis should prompt further imaging and urological evaluation to assess for the presence of a renal mass and potential venous involvement.</li><li>➤ patient with a significant smoking history</li><li>➤ painless scrotal mass andhematuria</li><li>➤ normal AFP and LDH levels</li><li>➤ renal cell carcinoma</li><li>➤ Ref : Bailey and Love’s Short Practice of surgery 28 th edition 1482</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of surgery 28 th edition 1482</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 40-year-old man presents with bloody urine for the past 10 days. His urine analysis report shows many RBCs, no casts or crystals. The kidney lesion's typical gross appearance post nephrectomy is depicted in the figure. Which of these hormonal levels could be elevated in this patient?", "options": [{"label": "A", "text": "Cortisol", "correct": false}, {"label": "B", "text": "Erythropoietin", "correct": true}, {"label": "C", "text": "Thyroxine", "correct": false}, {"label": "D", "text": "Vitamin D- Calcium", "correct": false}], "correct_answer": "B. Erythropoietin", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_r6piXka.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B) Erythropoietin</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Cortisol production is typically associated with adrenal tumors such as adenomas or carcinomas of the adrenal cortex , not commonly with RCC.</li><li>• Option A: Cortisol production</li><li>• associated with adrenal tumors</li><li>• adenomas or carcinomas</li><li>• adrenal cortex</li><li>• Option C: Ectopic production of thyroid hormones , such as thyroxine , is not commonly associated with RCC . Thyroid function abnormalities are typically related to thyroid pathologies.</li><li>• Option C: Ectopic production</li><li>• thyroid hormones</li><li>• thyroxine</li><li>• not commonly associated with RCC</li><li>• Option D: Calcium (Calcitriol) RCC can lead to increased production of calcitriol by the tumor , which may cause hypercalcemia , another common paraneoplastic syndrome seen in RCC. However, it is less commonly reported than erythropoietin production leading to polycythemia.</li><li>• Option D: Calcium</li><li>• RCC can lead to increased production of calcitriol by the tumor</li><li>• cause hypercalcemia</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In patients with renal cell carcinoma , paraneoplastic syndromes can manifest with the ectopic production of hormones such as erythropoietin , leading to secondary polycythemia .</li><li>➤ renal cell carcinoma</li><li>➤ paraneoplastic syndromes</li><li>➤ ectopic production of hormones such as erythropoietin</li><li>➤ secondary polycythemia</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition 1482</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition 1482</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 5-year-old girl with a history of recurrent urinary tract infections is admitted with clinical symptoms of fever, dysuria, and cloudy urine for the last 3 months. Urine exam shows significant bacteriuria (&gt;50,000). Which of the following is the most common etiology for chronic pyelonephritis?", "options": [{"label": "A", "text": "Reflux nephropathy", "correct": true}, {"label": "B", "text": "Renal stone", "correct": false}, {"label": "C", "text": "Posterior urethral valve", "correct": false}, {"label": "D", "text": "Urinary TB", "correct": false}], "correct_answer": "A. Reflux nephropathy", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/26/screenshot-2024-03-26-162324.png"], "explanation": "<p><strong>Ans. A) Reflux nephropathy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: While renal stones can cause obstruction and recurrent infections leading to pyelonephritis , they are less frequently the underlying cause of chronic pyelonephritis compared to VUR.</li><li>• Option B:</li><li>• renal stones</li><li>• cause obstruction and recurrent infections leading to pyelonephritis</li><li>• Option C: The posterior urethral valve is a congenital condition seen primarily in males , which can lead to urinary obstruction and secondary infections . However, it is not the most common cause of chronic pyelonephritis in females.</li><li>• Option C: The posterior urethral valve</li><li>• congenital condition seen primarily in males</li><li>• lead to urinary obstruction</li><li>• secondary infections</li><li>• Option D: Urinary TB will show sterile pyuria .</li><li>• Option D: Urinary TB</li><li>• sterile pyuria</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most common cause of chronic pyelonephritis , especially in the context of recurrent urinary tract infections and symptoms suggestive of an active infection, is reflux nephropathy .</li><li>➤ most common cause of chronic pyelonephritis</li><li>➤ context of recurrent urinary tract infections</li><li>➤ active infection, is reflux nephropathy</li><li>➤ The most common cause of chronic pyelonephritis is reflux nephropathy</li><li>➤ chronic pyelonephritis is reflux nephropathy</li><li>➤ Reflux nephropathy / Vesicoureteric reflux:</li><li>➤ Reflux nephropathy / Vesicoureteric reflux:</li><li>➤ Vesicoureteric reflux is back-flowing urine from the bladder to the ureters.</li><li>➤ Symptoms of vesicoureteral reflux:</li><li>➤ Symptoms of vesicoureteral reflux:</li><li>➤ Urgency, frequency of urination Burning when urinating Cloudy urine Fever Pain in the side flank of the abdomen</li><li>➤ Urgency, frequency of urination</li><li>➤ Burning when urinating</li><li>➤ Cloudy urine</li><li>➤ Fever</li><li>➤ Pain in the side flank of the abdomen</li><li>➤ Management:</li><li>➤ Management:</li><li>➤ Antibiotics and symptomatic treatment Surgical therapy to correct the defect</li><li>➤ Antibiotics and symptomatic treatment</li><li>➤ Surgical therapy to correct the defect</li><li>➤ Complications:</li><li>➤ Complications:</li><li>➤ End-stage renal failure</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1476</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1476</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 2-year-old boy presents with persistent abdominal pain since a week and fever to the casualty. He has a mass on palpation on the right side of the abdomen. A CT scan is done which shows a mass arising from the right kidney. He undergoes surgery for the same and the mass is excised. Identify the condition from the image shown below:", "options": [{"label": "A", "text": "Grawitz tumour", "correct": false}, {"label": "B", "text": "Angiomyolipoma", "correct": false}, {"label": "C", "text": "Nephroblastoma", "correct": true}, {"label": "D", "text": "Neuroblastoma", "correct": false}], "correct_answer": "C. Nephroblastoma", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_aqlqkMa.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Nephroblastoma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Also known as renal cell carcinoma (RCC), Grawitz tumor is generally an adult malignancy . It is rare in children and does not typically present as a sensitive mass in the abdomen in a 2-year-old.</li><li>• Option A:</li><li>• renal cell carcinoma</li><li>• Grawitz tumor</li><li>• adult malignancy</li><li>• rare in children</li><li>• Option B: An angiomyolipoma is a benign tumor composed of blood vessels , smooth muscle , and fat . It is typically seen in adults and is often associated with tuberous sclerosis, not commonly presenting as a sensitive abdominal mass in infancy.</li><li>• Option B:</li><li>• angiomyolipoma is a benign tumor composed of blood vessels</li><li>• smooth muscle</li><li>• fat</li><li>• Option D: A neuroblastoma is a childhood tumor arising from neural crest cells , typically found in the adrenal gland or paraspinal region . While it can present with an abdominal mass, it often crosses the midline, which is not suggested in this scenario. It doesn’t arise from kidney, and is seen in infants.</li><li>• Option D:</li><li>• neuroblastoma is a childhood tumor</li><li>• neural crest cells</li><li>• adrenal gland or paraspinal region</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most common kidney neoplasm in children, presenting with an abdominal mass, fever, and potential hematuria, is balso known as Wilms' tumor. The management of this condition includes surgical resection followed by chemotherapy based on staging .</li><li>➤ kidney neoplasm in children,</li><li>➤ abdominal mass, fever, and potential hematuria,</li><li>➤ Wilms' tumor.</li><li>➤ management of this condition includes surgical resection followed by chemotherapy based on staging</li><li>➤ Wilms tumour/Nephroblastoma:</li><li>➤ Wilms tumour/Nephroblastoma:</li><li>➤ It is the most prevalent kidney neoplasm in children. Presentation - palpable, painless abdominal mass (first sign), fever, and hematuria Genetic basis of disease – Modification in WT1 or WT2 genes on chromosome 11, the WTX gene and the AMER1 gene on the X chromosome, and the CTNNB1 gene on chromosome 3. WAGR syndrome : Wilms + Aniridia + Genitourinary abnormalities + Retardation Diagnosis : CECT abdomen- Renal mass without calcification Treatment : Surgery + chemotherapy (National Wilms tumour staging group).</li><li>➤ It is the most prevalent kidney neoplasm in children.</li><li>➤ Presentation - palpable, painless abdominal mass (first sign), fever, and hematuria</li><li>➤ Presentation</li><li>➤ Genetic basis of disease – Modification in WT1 or WT2 genes on chromosome 11, the WTX gene and the AMER1 gene on the X chromosome, and the CTNNB1 gene on chromosome 3.</li><li>➤ WAGR syndrome : Wilms + Aniridia + Genitourinary abnormalities + Retardation</li><li>➤ WAGR syndrome</li><li>➤ Diagnosis : CECT abdomen- Renal mass without calcification</li><li>➤ Diagnosis</li><li>➤ Treatment : Surgery + chemotherapy (National Wilms tumour staging group).</li><li>➤ Treatment</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1484.</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1484.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In complete duplication of ureters, how does the proximal segment insert inside the urinary bladder?", "options": [{"label": "A", "text": "Cephalic and medial", "correct": false}, {"label": "B", "text": "Caudal and medial", "correct": true}, {"label": "C", "text": "Cephalic and lateral", "correct": false}, {"label": "D", "text": "Caudal and Lateral", "correct": false}], "correct_answer": "B. Caudal and medial", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/26/screenshot-2024-03-26-163041.png"], "explanation": "<p><strong>Ans. B) Caudal and medial</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Ectopic ureters are usually associated with duplicate ureters (in 80% cases) Weigert - Meyer rule of Ectopic ureters :</li><li>• Ectopic ureters are usually associated with duplicate ureters (in 80% cases)</li><li>• Ectopic ureters</li><li>• duplicate ureters</li><li>• Weigert - Meyer rule of Ectopic ureters :</li><li>• Weigert</li><li>• Meyer rule of Ectopic ureters</li><li>• Weigert Meyer rule states that the upper pole ureter is the ectopic ureter and its orifice inserts infero-medially in the bladder in relationship to the lower pole normal ureter .</li><li>• Weigert Meyer rule</li><li>• upper pole ureter is the ectopic ureter</li><li>• orifice inserts infero-medially in the bladder in relationship</li><li>• lower pole normal ureter</li><li>• The ureter that drains the upper moiety is at a more inferior and medial position and is prone to obstruction and dysplasia .</li><li>• ureter that drains the upper moiety</li><li>• more inferior and medial position</li><li>• prone to obstruction and dysplasia</li><li>• The ureter that drains the lower moiety is at a more superior and lateral position and is prone to VUR.</li><li>• ureter that drains the lower moiety</li><li>• more superior and lateral position</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ In complete duplication of ureters , the proximal segment inserts into the urinary bladder caudally and medially.</li><li>➤ complete duplication of ureters</li><li>➤ proximal segment</li><li>➤ urinary bladder caudally and medially.</li><li>➤ Most common symptom:</li><li>➤ Most common symptom:</li><li>➤ In males - Usually asymptomatic. In females - Incontinence (paradoxical incontinence) Ectopic opening below the external urethral sphincter leads to urinary incontinence.</li><li>➤ In males - Usually asymptomatic.</li><li>➤ In females - Incontinence (paradoxical incontinence)</li><li>➤ Ectopic opening below the external urethral sphincter leads to urinary incontinence.</li><li>➤ \"continuous incontinence in a girl with an otherwise normal voiding pattern after toilet training is the classic symptom of an ectopic ureteral orifice”</li><li>➤ Treatment: Reimplantation of ureter is done, if the kidney is scarred.</li><li>➤ Treatment:</li><li>➤ Ref : Bailey and Love’s Short Practice of surgery 28 th edition pg 1468</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of surgery 28 th edition pg 1468</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these statements regarding Renal cell carcinoma is false?", "options": [{"label": "A", "text": "Most common type overall is Clear cell RCC", "correct": false}, {"label": "B", "text": "Most common seen in dialysis patients is papillary RCC", "correct": false}, {"label": "C", "text": "Most common seen in sickle cell trait patients is medullary RCC", "correct": false}, {"label": "D", "text": "Best prognosis is seen in Papillary RCC", "correct": true}], "correct_answer": "D. Best prognosis is seen in Papillary RCC", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Best prognosis is seen in Papillary RCC</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: The most prevalent type of RCC is clear cell RCC , which accounts for approximately 70-80% of all cases . It is characterized histologically by cells with a clear cytoplasm due to the high lipid and glycogen content.</li><li>• Option A: The most prevalent type of RCC</li><li>• clear cell RCC</li><li>• accounts for approximately 70-80% of all cases</li><li>• Option B: In patients with end-stage renal disease who are on dialysis, papillary RCC is more commonly seen compared to other types . This type of RCC often presents as multiple bilateral tumors and can be sporadic or hereditary.</li><li>• Option B: In patients with end-stage renal disease who are on dialysis, papillary</li><li>• seen compared to other types</li><li>• Option C: Patients with the sickle cell trait are more likely to develop renal medullary carcinoma , which is a rare and aggressive type of kidney cancer , rather than RCC.</li><li>• Option C:</li><li>• sickle cell trait</li><li>• renal</li><li>• medullary carcinoma</li><li>• rare and aggressive type of kidney cancer</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Among the various subtypes of renal cell carcinoma, chromophobe RCC is associated with the best prognosis, not papillary RCC . Clear cell RCC is the most common type overall, papillary RCC is more commonly seen in dialysis patients , and renal medullary carcinoma , which is closely associated with sickle cell trait , is considered a separate entity due to its distinct pathology and aggressive behavior.</li><li>➤ subtypes of renal cell carcinoma,</li><li>➤ chromophobe RCC is associated with the best prognosis, not papillary RCC</li><li>➤ Clear cell RCC</li><li>➤ common type</li><li>➤ papillary RCC</li><li>➤ commonly seen in dialysis patients</li><li>➤ renal medullary carcinoma</li><li>➤ closely associated with sickle cell trait</li><li>➤ The best prognosis is seen in – Chromophobe RCC The most common type overall is Clear cell RCC Most common seen in dialysis patients is papillary RCC Most common seen in sickle cell trait patients is medullary RCC</li><li>➤ The best prognosis is seen in – Chromophobe RCC</li><li>➤ The most common type overall is Clear cell RCC</li><li>➤ Most common seen in dialysis patients is papillary RCC</li><li>➤ Most common seen in sickle cell trait patients is medullary RCC</li><li>➤ Ref : Bailey and Love’s Short Practice of surgery 28 th edition Pg 1482</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of surgery 28 th edition Pg 1482</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is true about T3a stage renal carcinoma:", "options": [{"label": "A", "text": "Involves Gerota fascia", "correct": false}, {"label": "B", "text": "Involve perinephric fat and renal vein", "correct": true}, {"label": "C", "text": "Involves Renal artery", "correct": false}, {"label": "D", "text": "Involves Inferior vena cava", "correct": false}], "correct_answer": "B. Involve perinephric fat and renal vein", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Involve perinephric fat and renal vein</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Involvement of Gerota's fascia would categorize the renal carcinoma as stage T4 , not T3a.</li><li>• Option A:</li><li>• Involvement of Gerota's fascia</li><li>• renal carcinoma as stage T4</li><li>• Option C: Direct involvement of the renal artery is not specified in the T3a stage.</li><li>• Option C: Direct involvement of the renal artery</li><li>• not specified in the T3a stage.</li><li>• Option D: IVC involvement is categorized as T3b if below the diaphragm or T3c if above the diaphragm and extending into the right atrium.</li><li>• Option D:</li><li>• IVC involvement</li><li>• T3b if below the diaphragm</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In the TNM staging system for renal cell carcinoma , T3a signifies tumor extension into the major veins or perinephric tissues but not beyond Gerota's fascia . It includes tumors with involvement of the perinephric fat and renal vein.</li><li>➤ TNM staging system for renal cell carcinoma</li><li>➤ T3a signifies tumor extension into the major veins or perinephric tissues</li><li>➤ not beyond Gerota's fascia</li><li>➤ TNM for RCC (AJCC 8 th Ed.):</li><li>➤ T1a- Tumour size up to 4 cm</li><li>➤ T1b- tumour size 4 to 7 cm</li><li>➤ T2- tumour size &gt; 7 cm</li><li>➤ T3a- Emboli into ipsilateral renal vein</li><li>➤ T3b- emboli into infra-diaphragmatic IVC</li><li>➤ T3c- Emboli into supra-diaphragmatic IVC</li><li>➤ T4- Breach of Gerota or invasion into Ipsilateral adrenal</li><li>➤ Ref : Bailey and Love’s Short Practice of surgery 28 th edition pg 1484</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of surgery 28 th edition pg 1484</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 60-year-old male presents with weight loss, gross hematuria, flank pain and a palpable abdominal mass. This is the CT scan of the patient which shows renal cell carcinoma with IVC extension. Which of these is not true regarding this condition?", "options": [{"label": "A", "text": "Five histologic types are seen in this condition", "correct": false}, {"label": "B", "text": "Preoperative biopsy is mandatory", "correct": true}, {"label": "C", "text": "A common presentation is gross hematuria", "correct": false}, {"label": "D", "text": "Chest X-ray can be done to rule out pulmonary metastasis", "correct": false}], "correct_answer": "B. Preoperative biopsy is mandatory", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_457nnI9.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B) Preoperative biopsy is mandatory</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: RCC includes several histologic subtypes , the most common of which is clear cell carcinoma . Other types include papillary, chromophobe, collecting duct (Bellini), and medullary carcinomas.</li><li>• Option A: RCC includes several histologic subtypes</li><li>• clear cell carcinoma</li><li>• Option C: Hematuria is indeed a common presenting symptom of RCC . It is typically gross rather than microscopic and can be associated with flank pain and a palpable mass.</li><li>• Option C: Hematuria</li><li>• common presenting symptom of RCC</li><li>• gross</li><li>• Option D: Chest radiography is a noninvasive and practical initial imaging study to evaluate for potential pulmonary metastases , which are common in advanced RCC.</li><li>• Option D: Chest radiography</li><li>• noninvasive and practical initial imaging study</li><li>• potential pulmonary metastases</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In the management of renal cell carcinoma , particularly when clear imaging findings are present , a preoperative biopsy is not mandatory and may be omitted to prevent potential seeding or complications. Imaging studies, clinical presentation, and histologic subtypes are crucial in the diagnosis and staging of RCC.</li><li>➤ management of renal cell carcinoma</li><li>➤ clear imaging findings are present</li><li>➤ preoperative biopsy is not mandatory and may be omitted to prevent potential seeding or complications.</li><li>➤ Pre-op biopsy is unnecessary as it is diagnosed with radiology and on a clinical basis. Presentation: Hematuria, flank pain, mass. Hematuria is the most common presentation. Chest X-ray could be done to rule out pulmonary “cannonball” metastasis. Five Histological subtypes are Clear cell carcinoma (MC), Papillary (Shows Psammoma body), Chromophobe type, Bellini duct and Medullary. Treatment: Partial (T1a, some T1b) or radical nephrectomy Occasionally, nephrectomy and removal of IVC tumour thrombus need to be done.</li><li>➤ Pre-op biopsy is unnecessary as it is diagnosed with radiology and on a clinical basis.</li><li>➤ Presentation: Hematuria, flank pain, mass. Hematuria is the most common presentation.</li><li>➤ Chest X-ray could be done to rule out pulmonary “cannonball” metastasis.</li><li>➤ Five Histological subtypes are Clear cell carcinoma (MC), Papillary (Shows Psammoma body), Chromophobe type, Bellini duct and Medullary.</li><li>➤ Treatment: Partial (T1a, some T1b) or radical nephrectomy</li><li>➤ Treatment:</li><li>➤ Occasionally, nephrectomy and removal of IVC tumour thrombus need to be done.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1482</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1482</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 16-year-old boy is brought to casualty by his parents because a cricket ball hit his left flank area which resulted in him passing blood in his urine. He also feels a fullness in his left loin. What could be the probable diagnosis?", "options": [{"label": "A", "text": "Renal cell carcinoma", "correct": false}, {"label": "B", "text": "Grawitz tumor", "correct": false}, {"label": "C", "text": "Congenital Hydronephrosis", "correct": true}, {"label": "D", "text": "Both A and B", "correct": false}], "correct_answer": "C. Congenital Hydronephrosis", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Congenital Hydronephrosis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Renal cell carcinoma is extremely rare in adolescents and is unlikely to present acutely after trauma.</li><li>• Option A: Renal cell carcinoma</li><li>• rare in adolescents</li><li>• Option B: Grawitz tumor , or renal cell carcinoma , is not typically associated with trauma and is uncommon in the pediatric population.</li><li>• Option B: Grawitz tumor</li><li>• renal cell carcinoma</li><li>• not typically associated with trauma</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Hematuria after minor trauma in a young patient is suggestive of an underlying renal pathology rather than a primary renal malignancy . A preexisting condition like congenital hydronephrosis due to PUJ obstruction could be exacerbated by trauma , leading to symptoms such as pain and a sensation of fullness due to urinary extravasation.</li><li>➤ Hematuria after minor trauma in a young patient</li><li>➤ underlying renal pathology</li><li>➤ primary renal malignancy</li><li>➤ preexisting condition like congenital hydronephrosis due to PUJ obstruction could be exacerbated by trauma</li><li>➤ pain and a sensation of fullness due to urinary extravasation.</li><li>➤ Hematuria following minor trauma occurs in a diseased kidney. The fullness in the left loin may be due to a congenital hydronephrosis from a pelvic-ureteric junction (PUJ) obstruction that has ruptured with urinary extravasation, thus causing the fullness in the left loin. Other Symptoms: Sudden or severe flank pain, nausea, frequent urination or painful urination, weakness, and hematuria.</li><li>➤ Hematuria following minor trauma occurs in a diseased kidney.</li><li>➤ The fullness in the left loin may be due to a congenital hydronephrosis from a pelvic-ureteric junction (PUJ) obstruction that has ruptured with urinary extravasation, thus causing the fullness in the left loin.</li><li>➤ Other Symptoms: Sudden or severe flank pain, nausea, frequent urination or painful urination, weakness, and hematuria.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28 th edition Pg 1468</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28 th edition Pg 1468</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old male presents with a history of fever and recurrent urinary tract infections. A CT abdomen reveals an enlarged right kidney with a characteristic ‘bear paw sign’ and multiple low-density areas consistent with necrosis or abscess formation. Which therapeutic intervention is most appropriate for this patient?", "options": [{"label": "A", "text": "Broad-spectrum antibiotics", "correct": false}, {"label": "B", "text": "Wait and watch", "correct": false}, {"label": "C", "text": "Surgery - subcapsular nephrectomy", "correct": true}, {"label": "D", "text": "DJ stenting", "correct": false}], "correct_answer": "C. Surgery - subcapsular nephrectomy", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/06/28/whatsapp-image-2023-06-12-at-1901251.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Surgery - Subcapsular nephrectomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: While antibiotics are necessary to treat the underlying infection , they may not be sufficient to manage the extensive disease suggested by the imaging.</li><li>• Option A:</li><li>• antibiotics</li><li>• treat the underlying infection</li><li>• not be sufficient to manage the extensive disease</li><li>• Option B: Observational management is not appropriate given the extent of the disease and the chronic symptoms , which indicate a progressed pathology unlikely to resolve without intervention.</li><li>• Option B: Observational management</li><li>• not appropriate</li><li>• extent of the disease and the chronic symptoms</li><li>• Option D: While DJ stenting is a common procedure to relieve obstruction, it is not a definitive treatment for XGP . The extent of tissue destruction typically necessitates more invasive surgical management.</li><li>• Option D: While DJ stenting</li><li>• procedure to relieve obstruction,</li><li>• not a definitive treatment for XGP</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ For a patient with xanthogranulomatous pyelonephritis, as suggested by the characteristic imaging findings, surgical removal of the affected kidney , typically via a subcapsular nephrectomy , is the preferred treatment to address the non-functioning mass of reactive tissue and alleviate chronic symptoms.</li><li>➤ xanthogranulomatous pyelonephritis,</li><li>➤ characteristic imaging findings, surgical removal of the affected kidney</li><li>➤ subcapsular nephrectomy</li><li>➤ preferred treatment to address the non-functioning mass</li><li>➤ reactive tissue</li><li>➤ Xanthogranulomatous pyelonephritis is, a chronic granulomatous process believed to be the result of subacute/chronic infection inciting a chronic but incomplete immune reaction. It occurs with severe renal infection in an obstructed kidney and is usually associated with calculi, causing loss of function and parenchymal destruction. The kidney is eventually replaced by a mass of reactive tissue. Foamy (lipid-laden) macrophages predominate on biopsy. Presentation: Fever, malaise, weight loss, low-grade fever, hematuria and flank pain. Treatment: Surgery - Subcapsular nephrectomy</li><li>➤ Xanthogranulomatous pyelonephritis is, a chronic granulomatous process believed to be the result of subacute/chronic infection inciting a chronic but incomplete immune reaction. It occurs with severe renal infection in an obstructed kidney and is usually associated with calculi, causing loss of function and parenchymal destruction. The kidney is eventually replaced by a mass of reactive tissue. Foamy (lipid-laden) macrophages predominate on biopsy.</li><li>➤ chronic granulomatous process</li><li>➤ Presentation: Fever, malaise, weight loss, low-grade fever, hematuria and flank pain.</li><li>➤ Presentation:</li><li>➤ Treatment: Surgery - Subcapsular nephrectomy</li><li>➤ Treatment:</li><li>➤ Ref : Bailey and Love’s Short Practice of surgery 28 th edition 1471</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of surgery 28 th edition 1471</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old male with chronic flank pain undergoes a contrast-enhanced computed tomography (CECT) scan of the abdomen. Based on the imaging characteristics, which of the following is the most appropriate diagnosis?", "options": [{"label": "A", "text": "Wilms tumour", "correct": false}, {"label": "B", "text": "Oncocytoma", "correct": true}, {"label": "C", "text": "Angiomyolipoma", "correct": false}, {"label": "D", "text": "Renal sarcoma", "correct": false}], "correct_answer": "B. Oncocytoma", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_iZtxUis.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/26/screenshot-2024-03-26-164408.png"], "explanation": "<p><strong>Ans. B) Oncocytoma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Wilms tumor , or nephroblastoma , is the most common renal malignancy in children , not typically diagnosed in adults. It usually does not present with a central stellate scar on imaging.</li><li>• Option A: Wilms tumor</li><li>• nephroblastoma</li><li>• most common renal malignancy in children</li><li>• Option C: Renal angiomyolipoma is another benign kidney tumor that commonly contains fat, muscle, and blood vessels. It is associated with tuberous sclerosis and can present with flank pain but does not typically show a central stellate scar on imaging.</li><li>• Option C: Renal angiomyolipoma</li><li>• benign kidney tumor</li><li>• contains fat, muscle, and blood vessels.</li><li>• Option D: Renal sarcoma is a rare type of malignant kidney tumor . It can be aggressive and often presents with more extensive local invasion and distant metastasis. A central stellate scar is not a typical feature of renal sarcomas on imaging.</li><li>• Option D: Renal sarcoma</li><li>• rare type of malignant kidney tumor</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Renal oncocytoma is characterized radiographically by a central stellate scar and histologically by nests of large eosinophilic cells . Though often asymptomatic , it may present with abdominal discomfort or a mass , and treatment can include partial nephrectomy, especially when the lesion is localized and amenable to nephron-sparing surgery.</li><li>➤ Renal oncocytoma</li><li>➤ radiographically by a central stellate scar</li><li>➤ histologically by nests of large eosinophilic cells</li><li>➤ asymptomatic</li><li>➤ may present with abdominal discomfort or a mass</li><li>➤ treatment can include partial nephrectomy,</li><li>➤ Presentation: Mostly asymptomatic but may present as an abdominal lump</li><li>➤ Presentation:</li><li>➤ Treatment: Partial nephrectomy.</li><li>➤ Treatment:</li><li>➤ Histologically: it can be confused with chromophobe RCC, particularly the eosinophilic variant. They may be differentiated by the use of immunohistochemistry staining, where chromophobe RCC stains positive for cytokeratin-7.</li><li>➤ Histologically:</li><li>➤ Ref : Bailey and Love’s 28 th Ed. Pg 1481</li><li>➤ Ref</li><li>➤ : Bailey and Love’s 28 th Ed. Pg 1481</li><li>➤ Campbell Walsh Urology 11 th edition pg 1306</li><li>➤ Campbell Walsh Urology 11 th edition pg 1306</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is a false statement regarding the anomaly shown in the picture below?", "options": [{"label": "A", "text": "It is associated with epispadias", "correct": false}, {"label": "B", "text": "More common in males", "correct": false}, {"label": "C", "text": "Bifid clitoris is seen in females", "correct": false}, {"label": "D", "text": "Abdominal wall closure should be done between 6 to 12 months of life", "correct": true}], "correct_answer": "D. Abdominal wall closure should be done between 6 to 12 months of life", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture4_RfouRLK.png"], "explanation_images": [], "explanation": "<p><strong>Ans. D) Abdominal wall closure should be done between 6 to 12 months of life.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Bladder exstrophy , as shown in the picture, is indeed commonly associated with epispadias, especially in males , due to the defect in the lower abdominal wall and subsequent exposure of the bladder.</li><li>• Option A: Bladder exstrophy</li><li>• commonly associated with epispadias, especially in males</li><li>• Option B: Bladder exstrophy is known to have a higher prevalence in males compared to females .</li><li>• Option B: Bladder exstrophy</li><li>• higher prevalence in males compared to females</li><li>• Option C: In females with bladder exstrophy , a bifid clitoris and a shortened , stenotic , and anteriorly displaced vagina are common findings.</li><li>• Option C:</li><li>• females with bladder exstrophy</li><li>• bifid clitoris and a shortened</li><li>• stenotic</li><li>• anteriorly displaced vagina</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Bladder exstrophy is a congenital malformation that typically requires early surgical intervention , often within the neonatal period, not between 6 to 12 months.</li><li>➤ Bladder exstrophy</li><li>➤ congenital malformation</li><li>➤ requires early surgical intervention</li><li>➤ not between 6 to 12 months.</li><li>➤ Bladder exstrophy (ectopia vesicae) is a congenital disorder in which failure of development of the lower abdominal wall leads to an abdominal wall defect through which the bladder is exposed. Treatment : The modern staged repair of exstrophy consists of bilateral iliac osteotomies with bladder exstrophy and abdominal wall closure in the neonatal period, followed by epispadias repair and phallic reconstruction at 6 months to 1 year of age, and finally bladder neck reconstruction and bilateral ureteral reimplantation (to treat VUR) at age 5-7 years.</li><li>➤ Bladder exstrophy (ectopia vesicae) is a congenital disorder in which failure of development of the lower abdominal wall leads to an abdominal wall defect through which the bladder is exposed.</li><li>➤ Bladder exstrophy</li><li>➤ congenital disorder</li><li>➤ failure of development of the lower abdominal wall leads to an abdominal wall defect</li><li>➤ Treatment : The modern staged repair of exstrophy consists of bilateral iliac osteotomies with bladder exstrophy and abdominal wall closure in the neonatal period, followed by epispadias repair and phallic reconstruction at 6 months to 1 year of age, and finally bladder neck reconstruction and bilateral ureteral reimplantation (to treat VUR) at age 5-7 years.</li><li>➤ Treatment</li><li>➤ Ref : Bailey and Love’s Short Practice of surgery 28 th edition pg 1492-1493</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of surgery 28 th edition pg 1492-1493</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "An 80-year-old male presents to the casualty with painless, profuse, and terminal hematuria. He is a chronic smoker with a 30-pack per year history. On analysis of urine there are atypical masses of urothelial cells found. What is the most probable diagnosis for the above-mentioned?", "options": [{"label": "A", "text": "Renal cell Ca", "correct": false}, {"label": "B", "text": "Adenocarcinoma of bladder", "correct": false}, {"label": "C", "text": "Transitional cell Ca of bladder", "correct": true}, {"label": "D", "text": "Squamous cell carcinoma of bladder", "correct": false}], "correct_answer": "C. Transitional cell Ca of bladder", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Transitional cell Ca of bladder</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A: While renal cell carcinoma can present with hematuria , it is typically not characterized by the presence of atypical urothelial cells in the urine.</li><li>• Option A:</li><li>• renal cell carcinoma</li><li>• present with hematuria</li><li>• Option B: Adenocarcinoma of the bladder is a rare type of bladder cancer and typically presents with irritative urinary symptoms and hematuria. However, urinalysis will not show urothelial cells.</li><li>• Option B: Adenocarcinoma of the bladder</li><li>• rare type of bladder cancer</li><li>• presents with irritative urinary symptoms and hematuria.</li><li>• Option D: Squamous cell carcinoma of the bladder is associated with chronic irritation and infection , not typically with smoking. It would also be less likely to present with atypical urothelial cells in the urine.</li><li>• Option D: Squamous cell carcinoma</li><li>• bladder is associated with chronic irritation</li><li>• infection</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In a patient with a significant smoking history who presents with painless , profuse, terminal hematuria and atypical urothelial cells in the urine , the most likely diagnosis is transitional cell carcinoma of the bladder . Urinalysis, cystoscopy, and biopsy are key diagnostic steps, with transurethral resection of bladder tumor (TURBT) being a common initial treatment.</li><li>➤ significant smoking history who presents with painless</li><li>➤ profuse, terminal hematuria and atypical urothelial cells in the urine</li><li>➤ transitional cell carcinoma of the bladder</li><li>➤ Bladder carcinoma:</li><li>➤ Bladder carcinoma:</li><li>➤ Clinical signs : Painless profuse hematuria, h/o smoking, anemia</li><li>➤ Clinical signs</li><li>➤ Diagnosis : Urine analysis - urothelial cells in the lining of the bladder that grow and become abnormal (seen in Transitional cell carcinoma of the bladder)</li><li>➤ Diagnosis</li><li>➤ IOC: Cystoscopy and biopsy.</li><li>➤ IOC: Cystoscopy and biopsy.</li><li>➤ Treatment - Transurethral resection of bladder tumor (TURBT) with intravesical chemotherapy or Radical cystectomy</li><li>➤ Treatment</li><li>➤ Ref : Bailey and Love’s Short Practice of surgery 28 th edition Pg 1515</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of surgery 28 th edition Pg 1515</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is not a common use of the device given below?", "options": [{"label": "A", "text": "Per urethral catheter", "correct": true}, {"label": "B", "text": "Suprapubic catheterization", "correct": false}, {"label": "C", "text": "Nephrostomy", "correct": false}, {"label": "D", "text": "ICD tube", "correct": false}], "correct_answer": "A. Per urethral catheter", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_bedBI4L.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. A) Per urethral catheter</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: The Malecot catheter is often used for suprapubic cystostomy due to its self-retaining design, which is ideal for suprapubic bladder drainage.</li><li>• Option B:</li><li>• Malecot catheter is often used for suprapubic cystostomy</li><li>• Option C: The Malecot catheter can be used as a nephrostomy tube to drain the renal pelvis when the ureter is obstructed.</li><li>• Option C:</li><li>• Malecot catheter can be used as a nephrostomy</li><li>• Option D: Though traditionally an ICD tube has a different design, the Malecot catheter can be used as an intercostal drain for chest drainage due to its large lumen and self-retaining capability.</li><li>• Option D:</li><li>• Malecot catheter can be used as an intercostal drain for chest drainage</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Malecot catheter is not suitable for per urethral catheterization due to its design . It is commonly used for suprapubic cystostomy , as a nephrostomy tube , and can also be adapted for use as an intercostal or abdominal drain .</li><li>➤ Malecot catheter</li><li>➤ not suitable for per urethral catheterization due to its design</li><li>➤ suprapubic cystostomy</li><li>➤ nephrostomy tube</li><li>➤ adapted for use as an intercostal or abdominal drain</li><li>➤ Malecot’s catheter</li><li>➤ Malecot’s catheter</li><li>➤ Flower tip- self-retaining Used in Supra-pubic cystostomy Non-urological uses include- Intercostal/abdominal drain, Feeding gastrostomy/jejunostomy Not for per urethral drainage</li><li>➤ Flower tip- self-retaining</li><li>➤ Used in Supra-pubic cystostomy</li><li>➤ Non-urological uses include- Intercostal/abdominal drain, Feeding gastrostomy/jejunostomy</li><li>➤ Not for per urethral drainage</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old patient got injured in the suprapubic area in an accident and he was rushed to the casualty. He has been unable to pass urine since the accident. On examination, no blood is seen at the meatus. On attempting Foley's catheterization, no urine was noticed. What will be the next step in the management of this patient?", "options": [{"label": "A", "text": "Exploratory Laparotomy", "correct": false}, {"label": "B", "text": "Supra-pubic cystostomy", "correct": false}, {"label": "C", "text": "CT urography/ cystogram", "correct": true}, {"label": "D", "text": "Wait and watch", "correct": false}], "correct_answer": "C. CT urography/ cystogram", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_qYqOmIN.jpg"], "explanation": "<p><strong>Ans. C) CT urography/ cystogram</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Exploratory Laparotomy: This invasive procedure is performed if there is evidence of intra-abdominal injury or if the diagnosis of intra-peritoneal bladder rupture was established.</li><li>• Option A: Exploratory Laparotomy:</li><li>• invasive procedure is performed if there is evidence of intra-abdominal injury</li><li>• Option B: Suprapubic Cystostomy: This could be a consideration if there is a need for urinary diversion due to a urethral rupture .</li><li>• Option B: Suprapubic Cystostomy:</li><li>• consideration if there is a need for urinary diversion</li><li>• urethral rupture</li><li>• Option D: Wait and Watch: This approach is not suitable for a suspected bladder injury , as it could lead to complications, including urinary ascites or infection.</li><li>• Option D: Wait and Watch:</li><li>• not suitable for a suspected bladder injury</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ For a patient with suspected blunt lower urinary tract trauma presenting with bladder rupture , the next step in management is to perform a CT urography or cystogram to evaluate for bladder rupture</li><li>➤ patient with suspected blunt lower urinary tract trauma</li><li>➤ bladder rupture</li><li>➤ next step in management is to perform a CT urography or cystogram</li><li>➤ bladder rupture</li><li>➤ Algorithm for management of suspected lower urinary tract trauma</li><li>➤ Algorithm for management of suspected lower urinary tract trauma</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28 th edition pg 1520</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28 th edition pg 1520</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 16-year-old boy holding his urine for a long time in the classroom, finally asks for permission to go to the toilet. While running on his way to the bathroom, he slips and falls and has a direct blow on his supra-pubic area. He passes out and is taken to the hospital by the school authorities. In the hospital he is unable to pass urine and his abdomen is distended. What would be the first step in this condition?", "options": [{"label": "A", "text": "Attempt a per-urethral catheter if no blood at meatus", "correct": true}, {"label": "B", "text": "Retrograde urethrogram", "correct": false}, {"label": "C", "text": "Surgical intervention", "correct": false}, {"label": "D", "text": "Close monitoring", "correct": false}], "correct_answer": "A. Attempt a per-urethral catheter if no blood at meatus", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Attempt a per-urethral catheter if no blood at meatus</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: A retrograde urethrogram should be performed to rule out urethral injury , if blood is seen at urethral meatus, not observed here.</li><li>• Option B:</li><li>• retrograde urethrogram</li><li>• performed to rule out urethral injury</li><li>• Option C: Surgical intervention may be necessary if there is a confirmed bladder rupture ; however, this would not be the immediate next step without diagnostic confirmation.</li><li>• Option C: Surgical intervention</li><li>• necessary if there is a confirmed bladder rupture</li><li>• Option D: A wait and watch approach could be attempted after ruling our bladder rupture .</li><li>• Option D:</li><li>• wait and watch approach</li><li>• after ruling our bladder rupture</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In cases of suspected bladder trauma with inability to void and abdominal distension , a per urethral catheter is the initial step followed by cystogram to confirm the diagnosis. Management depends on whether the injury is extraperitoneal or intraperitoneal , with surgical repair being necessary for intraperitoneal ruptures .</li><li>➤ suspected bladder trauma</li><li>➤ inability to void and abdominal distension</li><li>➤ per urethral catheter</li><li>➤ initial step followed by cystogram</li><li>➤ Management</li><li>➤ whether the injury is extraperitoneal or intraperitoneal</li><li>➤ surgical repair</li><li>➤ intraperitoneal ruptures</li><li>➤ Bladder trauma</li><li>➤ Bladder trauma</li><li>➤ Bladder trauma can be extraperitoneal or intraperitoneal. Extraperitoneal injury can be managed with indwelling catheterization for 10–14 days. Intraperitoneal injury most often requires laparotomy and repair of the bladder defect.</li><li>➤ Bladder trauma can be extraperitoneal or intraperitoneal.</li><li>➤ Extraperitoneal injury can be managed with indwelling catheterization for 10–14 days.</li><li>➤ Intraperitoneal injury most often requires laparotomy and repair of the bladder defect.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28 th edition pg 1520</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28 th edition pg 1520</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 40-year-old man presents to the casualty after a motor vehicle accident with severe hypogastric and flank pain. He is tachycardic, confused, and on examination shows abdominal guarding with rebound tenderness. There is no blood at the urethral orifice. On catheterization there is no urine. Retrograde cystography image is shown below. What would be the next step in management?", "options": [{"label": "A", "text": "Supra-pubic cystostomy", "correct": false}, {"label": "B", "text": "Foleys catheter drainage", "correct": false}, {"label": "C", "text": "Wait and watch", "correct": false}, {"label": "D", "text": "Exploratory laparotomy", "correct": true}], "correct_answer": "D. Exploratory laparotomy", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture4_WKswy5D.png"], "explanation_images": [], "explanation": "<p><strong>Ans. D) Exploratory laparotomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Supra-pubic Cystostomy: While a supra-pubic cystostomy may eventually be necessary for bladder drainage , the immediate concern in this case is addressing the intraperitoneal bladder rupture and potential peritonitis, which requires surgical exploration.</li><li>• Option A: Supra-pubic Cystostomy:</li><li>• necessary for bladder drainage</li><li>• Option B: Foley's Catheter Drainage: Bladder catheterization is inadequate in cases of suspected intraperitoneal bladder rupture , as controlling peritonitis is the primary aim.</li><li>• Option B: Foley's Catheter Drainage:</li><li>• Bladder catheterization</li><li>• suspected intraperitoneal bladder rupture</li><li>• Option C: Wait and Watch: Given the severity of the patient's condition and the risk of peritonitis, a conservative \"wait and watch\" approach without immediate intervention is not appropriate.</li><li>• Option C: Wait and Watch:</li><li>• the risk of peritonitis, a conservative \"wait and watch\" approach</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In cases of suspected intraperitoneal bladder rupture with signs of peritonitis and inability to pass urine , the definitive management is exploratory laparotomy to assess and repair the bladder injury , along with peritoneal lavage and potential bladder drainage with a supra-pubic catheter.</li><li>➤ suspected intraperitoneal bladder rupture</li><li>➤ signs of peritonitis</li><li>➤ inability to pass urine</li><li>➤ definitive management is exploratory laparotomy to assess</li><li>➤ repair the bladder injury</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1520</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1520</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A surgery resident is trying to remove a Foleys catheter, but he is unable to deflate the balloon, despite cutting the side arm. Which of the following maneuvers would be useful in removing the catheter?", "options": [{"label": "A", "text": "Inflate with Ether", "correct": false}, {"label": "B", "text": "Under USG guidance, locate and puncture the balloon", "correct": true}, {"label": "C", "text": "Exploratory laparotomy to remove the foleys", "correct": false}, {"label": "D", "text": "Inject water to over distend the balloon until it bursts and remove the catheter", "correct": false}], "correct_answer": "B. Under USG guidance, locate and puncture the balloon", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Under USG guidance, locate and puncture the balloon</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Inflating the Foley catheter balloon with ether is not a recommended technique as it can cause tissue damage and other complications. Ether is a volatile and flammable substance that is not suitable for medical procedures like inflating catheter balloons.</li><li>• Option A: Inflating the Foley catheter balloon</li><li>• ether is not a recommended technique as it can cause tissue damage</li><li>• Ether is a volatile and flammable substance</li><li>• Option C: Performing an exploratory laparotomy to remove a Foley catheter is an invasive and unnecessary procedure for managing difficulty in catheter removal . It should only be considered if other less invasive methods fail and there are significant complications or concerns.</li><li>• Option C: Performing an exploratory laparotomy to remove a Foley catheter</li><li>• invasive and unnecessary procedure for managing difficulty in catheter removal</li><li>• Option D: Over-distending the Foley catheter balloon until it bursts is not recommended as it can cause injury to the urethra or bladder and may lead to complications such as urinary tract infection or bleeding. It is a risky and inappropriate method for catheter removal.</li><li>• Option D: Over-distending</li><li>• Foley catheter balloon until it bursts is not recommended as it can cause injury to the urethra or bladder</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ When unable to remove a Foley catheter easily , cutting the side arm , inflating with 20 ml of water , and under ultrasound guidance, locating and puncturing the balloon is a safe and effective method for facilitating catheter removal.</li><li>➤ unable to remove a Foley catheter easily</li><li>➤ cutting the side arm</li><li>➤ inflating with 20 ml of water</li><li>➤ under ultrasound guidance,</li><li>➤ locating and puncturing the balloon</li><li>➤ safe</li><li>➤ Ref : Online resource https://academic.oup.com/bja/article/doi/10.1093/bja/el_8886/2451253</li><li>➤ Ref</li><li>➤ : Online resource</li><li>➤ https://academic.oup.com/bja/article/doi/10.1093/bja/el_8886/2451253</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "What will be the outer diameter of a 12 French size foley’s catheter?", "options": [{"label": "A", "text": "2 mm", "correct": false}, {"label": "B", "text": "3 mm", "correct": false}, {"label": "C", "text": "4 mm", "correct": true}, {"label": "D", "text": "6 mm", "correct": false}], "correct_answer": "C. 4 mm", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) 4 mm</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• French size of Foleys catheter = 3 x outer diameter in mm</li><li>• French size of Foleys catheter</li><li>• 3 x outer diameter in mm</li><li>• In the given question, for 12F Foley’s, outer diameter will be 12F/3= 4 mm .</li><li>• for 12F Foley’s, outer diameter will be 12F/3= 4 mm</li><li>• (The French scale is derived from the ratio of circumference to diameter of a circle. French represents the circumference. Thus, French to mm conversion is actually Circumference (F) = Pi (3.14) x diameter (mm).</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ French size of Foleys catheter = 3 x outer diameter in mm</li><li>➤ French size of Foleys catheter = 3 x outer diameter in mm</li><li>➤ The standard catheter size for uncomplicated urethral catheterization in women is 12Fr or 14Fr, and in men 16Fr. In patients with urethral stricture, a smaller size catheter should be considered. In cases of haematuria with ‘clot retention’, a 22Fr catheter is typically used to aid drainage of thick clots</li><li>➤ The standard catheter size for uncomplicated urethral catheterization in women is 12Fr or 14Fr, and in men 16Fr.</li><li>➤ In patients with urethral stricture, a smaller size catheter should be considered.</li><li>➤ In cases of haematuria with ‘clot retention’, a 22Fr catheter is typically used to aid drainage of thick clots</li><li>➤ Ref : Bailey and Love’s Short Practice of surgery 28 th edition pg 1508</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of surgery 28 th edition pg 1508</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old male smoker presents with complaints of hematuria and difficulty passing urine. On ultrasound KUB a mass in his urinary bladder is seen, and on cystoscopy – biopsy it is confirmed as urothelial cell carcinoma. Which of the following is not true regarding urothelial cell carcinoma of the bladder?", "options": [{"label": "A", "text": "The commonest type of bladder cancer is transitional cell (urothelial) carcinoma", "correct": false}, {"label": "B", "text": "Schistosomiasis causes Squamous cell carcinoma", "correct": false}, {"label": "C", "text": "Phenacetin and cyclophosphamide are used for treatment of Ca bladder", "correct": true}, {"label": "D", "text": "Most common symptom is painless hematuria", "correct": false}], "correct_answer": "C. Phenacetin and cyclophosphamide are used for treatment of Ca bladder", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Phenacetin and cyclophosphamide are used for treatment of Ca bladder</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Transitional cell carcinoma , also known as urothelial carcinoma , is the most common type of bladder cancer, accounting for the majority of cases . It arises from the transitional epithelial cells lining the bladder.</li><li>• Option A: Transitional cell carcinoma</li><li>• urothelial carcinoma</li><li>• most common type of bladder cancer,</li><li>• majority of cases</li><li>• Option B: Schistosomiasis , a parasitic infection , is associated with the development of squamous cell carcinoma of the bladder . Chronic inflammation due to the presence of Schistosoma parasites can lead to the development of this type of cancer.</li><li>• Option B: Schistosomiasis</li><li>• parasitic infection</li><li>• development of squamous cell carcinoma of the bladder</li><li>• Option D: The most common symptom of bladder cancer is painless hematuria , which occurs in approximately 85% of patients. Other symptoms may include urinary frequency, urgency, dysuria, and recurrent urinary tract infections.</li><li>• Option D:</li><li>• most common symptom of bladder cancer is painless hematuria</li><li>• approximately 85% of patients.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Urothelial cell carcinoma of the bladder , also known as transitional cell carcinoma , is the most common type of bladder cancer , typically presenting with painless hematuria as the most common symptom . Phenacetin and cyclophosphamide are associated with the development of bladder cancer , not used for treatment.</li><li>➤ Urothelial cell carcinoma of the bladder</li><li>➤ transitional cell carcinoma</li><li>➤ common type of bladder cancer</li><li>➤ presenting with painless hematuria</li><li>➤ most common symptom</li><li>➤ Phenacetin and cyclophosphamide</li><li>➤ development of bladder cancer</li><li>➤ Squamous cell carcinoma occurs secondary to chronic inflammation (e.g. indwelling catheter, stone, schistosomiasis), and primary adenocarcinoma usually originates in the urachus (dome of the bladder) or in those with bowel in the urinary tract (augmentation entero- cystoplasty, bladder exstrophy repair). Patients most commonly present with painless haematuria (in 85%). Storage lower urinary tract symptoms (LUTS) of frequency, urgency, dysuria and recurrent UTI may be present.</li><li>➤ Squamous cell carcinoma occurs secondary to chronic inflammation (e.g. indwelling catheter, stone, schistosomiasis), and primary adenocarcinoma usually originates in the urachus (dome of the bladder) or in those with bowel in the urinary tract (augmentation entero- cystoplasty, bladder exstrophy repair).</li><li>➤ Squamous cell carcinoma</li><li>➤ secondary to chronic inflammation</li><li>➤ primary adenocarcinoma</li><li>➤ originates in the urachus</li><li>➤ those with bowel in the urinary tract</li><li>➤ Patients most commonly present with painless haematuria (in 85%). Storage lower urinary tract symptoms (LUTS) of frequency, urgency, dysuria and recurrent UTI may be present.</li><li>➤ Ref : Bailey and Love’s Short Practice of surgery 28 th edition pg 1516</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of surgery 28 th edition pg 1516</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old man is posted for cystoscopy biopsy in a case of suspected bladder cancer. The tumor is found to be invading the muscularis propria of the the bladder wall. What is the pathological stage of the tumor?", "options": [{"label": "A", "text": "T1", "correct": false}, {"label": "B", "text": "T2", "correct": true}, {"label": "C", "text": "T3", "correct": false}, {"label": "D", "text": "T4", "correct": false}], "correct_answer": "B. T2", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) T2</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Staging of Ca Bladder:</li><li>• Staging of Ca Bladder:</li><li>• Tx- Primary tumor cannot be assessed</li><li>• T0- No evidence of primary tumor</li><li>• pTa- Non-invasive papillary carcinoma (not invading lamina propria)</li><li>• pTis- Carcinoma in situ</li><li>• pT1-Tumor invades subepithelial connective tissue (lamina propria)</li><li>• pT2- Tumor invades muscularis propria bladder wall</li><li>• pT3- Tumor invades perivesical tissue</li><li>• pT4- Tumor invades any of the following: Prostate, uterus, vagina, pelvic wall and abdominal wall.</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• The tumor invading the muscularis propria bladder wall corresponds to pathological stage T2.</li><li>• tumor invading the muscularis propria bladder wall</li><li>• pathological stage T2.</li><li>• Ref : Bailey and Love’s Short Practice of surgery 28 th edition pg 1516</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of surgery 28 th edition pg 1516</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old female presents with painless hematuria. On cystoscopic evaluation, papillary mass of 0.5 cm is excised. HP reveals tumors restricted to lamina propria. What will be the management?", "options": [{"label": "A", "text": "Surveillance", "correct": false}, {"label": "B", "text": "Cystoscopic re-excision + intravesical chemotherapy", "correct": true}, {"label": "C", "text": "Single intravesical chemotherapy", "correct": false}, {"label": "D", "text": "Radical cystectomy", "correct": false}], "correct_answer": "B. Cystoscopic re-excision + intravesical chemotherapy", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Cystoscopic re-excision + Intravesical chemotherapy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• This tumor is in the pT1 stage.</li><li>• This tumor is in the pT1 stage.</li><li>• pTa- Single cycle intravesical chemotherapy</li><li>• pT1 or high grade pTa- Repeat TURBT at 2 to 6 weeks + intravesical chemotherapy</li><li>• pT2, pT3: Radical cystectomy</li><li>• pT4: Palliative systemic chemotherapy/radiotherapy</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The management of a bladder tumor restricted to the lamina propria (pT1 stage) involves cystoscopic re-excision followed by intravesical chemotherapy to reduce the risk of recurrence and progression.</li><li>➤ management of a bladder tumor</li><li>➤ lamina propria</li><li>➤ involves cystoscopic re-excision</li><li>➤ Ref : Bailey 28 th Ed. Pg 1518.</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 1518.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these strains of Mycobacteria will be useful in treatment of patients with non-muscle invasive urinary bladder tumors?", "options": [{"label": "A", "text": "Mycobacterium tuberculosis complex", "correct": false}, {"label": "B", "text": "Mycobacterium bovis", "correct": true}, {"label": "C", "text": "Mycobacterium avium complex", "correct": false}, {"label": "D", "text": "Mycobacterium paratuberculosis", "correct": false}], "correct_answer": "B. Mycobacterium bovis", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Mycobacterium bovis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Mycobacterium tuberculosis complex: The Mycobacterium tuberculosis complex includes various strains of mycobacteria that cause tuberculosis in humans, such as Mycobacterium tuberculosis. These strains are not used in the treatment of non-muscle invasive urinary bladder tumors.</li><li>• Option A: Mycobacterium tuberculosis complex:</li><li>• includes various strains of mycobacteria</li><li>• cause tuberculosis in humans,</li><li>• Mycobacterium tuberculosis.</li><li>• Option C: Mycobacterium avium complex: The Mycobacterium avium complex consists of several species , including Mycobacterium avium and Mycobacterium intracellulare . These species are primarily associated with opportunistic infections in immunocompromised individuals and are not used in the treatment of bladder tumors.</li><li>• Option C: Mycobacterium avium complex:</li><li>• consists of several species</li><li>• Mycobacterium avium</li><li>• Mycobacterium intracellulare</li><li>• Option D: Mycobacterium paratuberculosis:</li><li>• Option D: Mycobacterium paratuberculosis:</li><li>• Mycobacterium paratuberculosis is the causative agent of Johne's disease , a chronic enteritis in ruminants . It is not relevant to the treatment of non-muscle invasive urinary bladder tumors.</li><li>• causative agent of Johne's disease</li><li>• chronic enteritis in ruminants</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Mycobacterium bovis is the strain used in intravesical BCG therapy , which is effective in reducing the risk of progression to muscle invasive bladder cancer in patients with non-muscle invasive urinary bladder tumors.</li><li>• Mycobacterium bovis</li><li>• strain used in intravesical BCG therapy</li><li>• effective in reducing the risk of progression to muscle invasive bladder cancer</li><li>• non-muscle invasive urinary bladder tumors.</li><li>• Intravesical BCG (intravesical bacillus Calmette–Guérin) is given for high-risk tumors , to reduce the risk of progression to Muscle invasive bladder cancer , uses an attenuated strain of Mycobacterium bovis by inducing a local inflammatory response against the attenuated bacteria, which helps in the destruction of the tumor cells. The major disease-causing groups of Mycobacterium are the Mycobacterium tuberculosis complex (tuberculosis), Mycobacterium avium complex (mycobacterium avium-intracellulare infection), M. leprae and M. lepromatosis (leprosy), and Mycobacterium abscessus (chronic lung infection).</li><li>• Intravesical BCG (intravesical bacillus Calmette–Guérin) is given for high-risk tumors , to reduce the risk of progression to Muscle invasive bladder cancer , uses an attenuated strain of Mycobacterium bovis by inducing a local inflammatory response against the attenuated bacteria, which helps in the destruction of the tumor cells.</li><li>• Intravesical BCG</li><li>• high-risk tumors</li><li>• reduce the risk of progression to Muscle invasive bladder cancer</li><li>• The major disease-causing groups of Mycobacterium are the Mycobacterium tuberculosis complex (tuberculosis), Mycobacterium avium complex (mycobacterium avium-intracellulare infection), M. leprae and M. lepromatosis (leprosy), and Mycobacterium abscessus (chronic lung infection).</li><li>• Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1518</li><li>• Ref</li><li>• : Bailey and Love’s short practice of surgery 28 th edition pg 1518</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is false regarding endemic bladder stones?", "options": [{"label": "A", "text": "Commonly associated with recurrence", "correct": true}, {"label": "B", "text": "High incidence in cereal-based diet", "correct": false}, {"label": "C", "text": "Peak incidence in 3 years old children in india", "correct": false}, {"label": "D", "text": "Most common type is ammonium urate or calcium oxalate", "correct": false}], "correct_answer": "A. Commonly associated with recurrence", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Commonly associated with recurrence</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: High incidence in cereal-based diet: True . Endemic bladder stones often occur in regions where children consume predominantly cereal-based diets that are low in animal protein and phosphate, contributing to the formation of stones.</li><li>• Option B: High incidence in cereal-based diet: True</li><li>• Option C: Peak incidence in 3 years old children in India: True . The peak incidence of primary bladder calculi, particularly in endemic regions like India, occurs in children younger than 10 years, with a peak around 2 to 4 years of age.</li><li>• Option C: Peak incidence in 3 years old children in India: True</li><li>• Option D: Most common type is ammonium urate or calcium oxalate: True. The most common components of primary bladder calculi include ammonium acid urate, calcium oxalate, uric acid, and calcium phosphate.</li><li>• Option D: Most common type is ammonium urate or calcium oxalate: True.</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Endemic bladder stones , particularly in children , are typically associated with cereal-based diets , peak in incidence during early childhood in regions like India , and are often composed of components like ammonium urate and calcium oxalate . Recurrence is rare after treatment.</li><li>• Endemic bladder stones</li><li>• children</li><li>• cereal-based diets</li><li>• peak in incidence during early childhood in regions like India</li><li>• composed of components like ammonium urate</li><li>• calcium oxalate</li><li>• Primary bladder calculi are more common in children exposed to low protein , low phosphate diets . Primary bladder calculi rarely recur after treatment. Childhood bladder lithiasis remains common in endemic regions , throughout a stone belt reaching from northern Africa , through the Middle east and the Balkans and into India, Japan, Thailand, and Indonesia,” Primary bladder calculi are most common in children younger than the age of 10, with a peak incidence at 2 to 4 years of age. The disease is much more common in boys than in girls. Stones are usually solitary and, once removed, rarely recur. Ammonium acid urate, calcium oxalate, uric acid, calcium phosphate are the most common components of primary bladder calculi. Children in endemic regions often consume a predominantly cereal based diet that is poor in animal protein and low in phosphate. Low dietary intake of phosphate not only leads to hypophosphatemia but also hyperammonemia, promoting the precipitation of both calcium oxalate and ammonium acid urate.</li><li>• Primary bladder calculi are more common in children exposed to low protein , low phosphate diets . Primary bladder calculi rarely recur after treatment.</li><li>• Primary bladder calculi</li><li>• common in children exposed to low protein</li><li>• low phosphate diets</li><li>• Childhood bladder lithiasis remains common in endemic regions , throughout a stone belt reaching from northern Africa , through the Middle east and the Balkans and into India, Japan, Thailand, and Indonesia,”</li><li>• Childhood bladder lithiasis</li><li>• common in endemic regions</li><li>• stone belt reaching from northern Africa</li><li>• Primary bladder calculi are most common in children younger than the age of 10, with a peak incidence at 2 to 4 years of age. The disease is much more common in boys than in girls.</li><li>• Stones are usually solitary and, once removed, rarely recur.</li><li>• Stones are usually solitary</li><li>• Ammonium acid urate, calcium oxalate, uric acid, calcium phosphate are the most common components of primary bladder calculi.</li><li>• Children in endemic regions often consume a predominantly cereal based diet that is poor in animal protein and low in phosphate.</li><li>• Low dietary intake of phosphate not only leads to hypophosphatemia but also hyperammonemia, promoting the precipitation of both calcium oxalate and ammonium acid urate.</li><li>• Ref : Bailey and Love’s short practice of surgery 28th edition pg 1509-1510</li><li>• Ref</li><li>• : Bailey and Love’s short practice of surgery 28th edition pg 1509-1510</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is not a contraindication for cystoscopy management of the disease shown in the image?", "options": [{"label": "A", "text": "Young patient with urethral stricture", "correct": false}, {"label": "B", "text": "Contracted bladder", "correct": false}, {"label": "C", "text": "Spiculated oxalate stone", "correct": true}, {"label": "D", "text": "Large triple phosphate stone", "correct": false}], "correct_answer": "C. Spiculated oxalate stone", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture4_TWdo5RO.png"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Spiculated oxalate stone</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Young patients with urethral stricture make it challenging to access the bladder with a cystoscope. This can be a contraindication for cystoscopic litholapaxy if urethral access cannot be achieved safely.</li><li>• Option A: Young patients with urethral stricture</li><li>• access the bladder with a cystoscope.</li><li>• Option B: A contracted bladder refers to a bladder with reduced capacity or decreased compliance , often due to chronic inflammation or neurological conditions. Performing cystoscopic litholapaxy in a contracted bladder can increase the risk of bladder perforation due to limited space and mobility.</li><li>• Option B: A contracted bladder</li><li>• bladder with reduced capacity or decreased compliance</li><li>• chronic inflammation or neurological conditions.</li><li>• Option D: Large bladder stones, including those composed of triple phosphate (struvite), can pose challenges during cystoscopic litholapaxy , especially if they are too large to be fragmented and removed safely.</li><li>• Option D: Large bladder stones,</li><li>• composed of triple phosphate</li><li>• pose challenges during cystoscopic litholapaxy</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Contraindications to cystoscopic litholapaxy for bladder stones include failure to access the urethra , presence of very large stones , and bladder pathologies like diverticula or a contracted bladder , but not the presence of spiculated oxalate stones.</li><li>• Contraindications to cystoscopic litholapaxy</li><li>• bladder stones</li><li>• failure to access the urethra</li><li>• presence of very large stones</li><li>• bladder pathologies like diverticula</li><li>• contracted bladder</li><li>• Contra-indications to cystoscopic litholapaxy:</li><li>• Failure to get urethral access: Young patients with stricture urethra, elderly with prostatomegaly. Very large stones Bladder pathologies like diverticula, contracted bladder (Risk of perforation)</li><li>• Failure to get urethral access: Young patients with stricture urethra, elderly with prostatomegaly.</li><li>• Very large stones</li><li>• Bladder pathologies like diverticula, contracted bladder (Risk of perforation)</li><li>• Ref : Bailey 28 th Ed. Pg 1510.</li><li>• Ref</li><li>• : Bailey 28 th Ed. Pg 1510.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "The procedure shown in the image is done along with:", "options": [{"label": "A", "text": "Neurogenic bladder", "correct": false}, {"label": "B", "text": "Radical cystectomy for bladder cancer", "correct": true}, {"label": "C", "text": "Ureteric injury during hysterectomy", "correct": false}, {"label": "D", "text": "Multiple ureteric calculi", "correct": false}], "correct_answer": "B. Radical cystectomy for bladder cancer", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_txgdZQy.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B) Radical cystectomy for bladder cancer</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Neurogenic bladder: Neurogenic bladder refers to a dysfunction of the urinary bladder due to neurological damage or dysfunction. While patients with neurogenic bladder may require surgical interventions, such as urinary diversion procedures, the specific procedure depicted in the image, ileal conduit urinary diversion, is typically performed in the context of radical cystectomy for bladder cancer and not specifically for neurogenic bladder.</li><li>• Option A: Neurogenic bladder:</li><li>• dysfunction of the urinary bladder due to neurological damage or dysfunction.</li><li>• neurogenic bladder may require surgical interventions,</li><li>• urinary diversion procedures,</li><li>• Option C: Ureteric injury during hysterectomy: During a hysterectomy , there is a risk of injury to nearby structures , including the ureters . While ureteric injuries may require surgical intervention, such as ureteric repair or reimplantation, the specific procedure depicted in the image, ileal conduit urinary diversion, is not typically performed in the context of ureteric injury during hysterectomy.</li><li>• Option C: Ureteric injury during hysterectomy:</li><li>• hysterectomy</li><li>• risk of injury to nearby structures</li><li>• ureters</li><li>• Option D: Multiple ureteric calculi: While patients with multiple ureteric calculi may require surgical intervention to remove the stones and relieve obstruction , the specific procedure depicted in the image, ileal conduit urinary diversion, is not typically performed to address ureteric calculi.</li><li>• Option D: Multiple ureteric calculi:</li><li>• multiple ureteric calculi</li><li>• surgical intervention to remove the stones and relieve obstruction</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Ileal conduit urinary diversion is commonly performed as part of radical cystectomy for bladder cancer to reroute urine flow after removal of the bladder.</li><li>• Ileal conduit urinary diversion</li><li>• part of radical cystectomy for bladder cancer to reroute urine flow</li><li>• removal of the bladder.</li><li>• The ileal conduit urinary diversion has the lowest rate of complications of all forms of urinary diversion . Risks include uretero-ileal leak or stricture (5%), stomal complications such as stenosis or hernia (20%), upper tract dilatation (30%), recurrent UTIs, and rarely metabolic complications (hyperchloremic metabolic acidosis).”</li><li>• The ileal conduit urinary diversion has the lowest rate of complications of all forms of urinary diversion . Risks include uretero-ileal leak or stricture (5%), stomal complications such as stenosis or hernia (20%), upper tract dilatation (30%), recurrent UTIs, and rarely metabolic complications (hyperchloremic metabolic acidosis).”</li><li>• ileal conduit urinary diversion</li><li>• lowest rate of complications of all forms of urinary diversion</li><li>• Ref : Bailey 28 th Ed. Pg 1518-19.</li><li>• Ref</li><li>• : Bailey 28 th Ed. Pg 1518-19.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 42-year-old woman presents to the clinic complaining of a 6-month history of pelvic pain and pressure that she believes is originating from her bladder. She describes the pain as persistent and worsening, and it seems to be related to her bladder filling. The pain temporarily improves with voiding. She also reports increased urinary frequency, nocturia, and a feeling of urgency. She has a history of irritable bowel syndrome and migraines. A cystoscopy is performed, which reveals red, bleeding patches on the bladder wall. Which of the following is the most likely diagnosis?", "options": [{"label": "A", "text": "Ca bladder", "correct": false}, {"label": "B", "text": "Interstitial cystitis", "correct": true}, {"label": "C", "text": "TB bladder", "correct": false}, {"label": "D", "text": "Schistosomiasis", "correct": false}], "correct_answer": "B. Interstitial cystitis", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_ZoMkWM8.jpg"], "explanation": "<p><strong>Ans. B) Interstitial cystitis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Carcinoma of the bladder typically presents with painless hematuria , rather than pelvic pain or pressure . It is also often associated with risk factors such as smoking or occupational exposure to certain chemicals, which are not mentioned here.</li><li>• Option A:</li><li>• Carcinoma of the bladder</li><li>• painless hematuria</li><li>• pelvic pain or pressure</li><li>• Option C: Tuberculosis of the bladder is typically a secondary site of infection from renal tuberculosis . Symptoms may include dysuria, frequency, and hematuria, but it is not usually associated with chronic pelvic pain or pressure, and systemic symptoms such as fever, night sweats, and weight loss might be present.</li><li>• Option C:</li><li>• Tuberculosis of the bladder</li><li>• secondary site of infection from renal tuberculosis</li><li>• Option D: Schistosomiasis of the bladder is caused by a parasitic infection and is endemic in certain regions . It can cause hematuria and fibrosis of the bladder but is less likely to cause chronic pelvic pain or pressure.</li><li>• Option D:</li><li>• Schistosomiasis of the bladder</li><li>• parasitic infection and is endemic in certain regions</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The correct diagnosis for a patient presenting with chronic pelvic pain or pressure , perceived to originate from the bladder , accompanied by urinary symptoms and cystoscopic findings of Hunner's ulcers , is interstitial cystitis (Option B).</li><li>➤ chronic pelvic pain or pressure</li><li>➤ originate from the bladder</li><li>➤ urinary symptoms</li><li>➤ cystoscopic findings of Hunner's ulcers</li><li>➤ interstitial cystitis</li><li>➤ Bladder pain syndrome (BPS)/ Interstitial cystitis is a chronic condition characterized by pelvic pain or pressure that is perceived to be originating from the bladder , accompanied by one or more urinary symptoms , including frequency, urgency and nocturia. Patients may have other associated chronic medical conditions (e.g. fibromyalgia, irritable bowel syndrome, migraines). Hunner’s ulcers are ulcerations in the fundus of the bladder seen in these patients</li><li>➤ Bladder pain syndrome (BPS)/ Interstitial cystitis is a chronic condition characterized by pelvic pain or pressure that is perceived to be originating from the bladder , accompanied by one or more urinary symptoms , including frequency, urgency and nocturia.</li><li>➤ Bladder pain syndrome</li><li>➤ chronic condition</li><li>➤ pelvic pain or pressure</li><li>➤ perceived to be originating from the bladder</li><li>➤ one or more urinary symptoms</li><li>➤ frequency, urgency and nocturia.</li><li>➤ Patients may have other associated chronic medical conditions (e.g. fibromyalgia, irritable bowel syndrome, migraines).</li><li>➤ Hunner’s ulcers are ulcerations in the fundus of the bladder seen in these patients</li><li>➤ Hunner’s ulcers</li><li>➤ ulcerations in the fundus of the bladder</li><li>➤ Treatment : Conservative management to intravesical instillation of drugs like glycosaminoglycan.</li><li>➤ Treatment : Conservative management to intravesical instillation of drugs like glycosaminoglycan.</li><li>➤ Treatment</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th edition pg 1513-1514</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th edition pg 1513-1514</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th edition pg 1513-1514</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which part of urethra would be injured in the pictures given below?", "options": [{"label": "A", "text": "Prostate", "correct": false}, {"label": "B", "text": "Penile", "correct": false}, {"label": "C", "text": "Bulbar", "correct": true}, {"label": "D", "text": "Membranous", "correct": false}], "correct_answer": "C. Bulbar", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_BoGQBQt.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Bulbar</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Straddle injuries lead to rupture of bulbous urethra. This can occur with a sharp blow to the perineum.</li><li>• Straddle injuries lead to rupture of bulbous urethra. This can occur with a sharp blow to the perineum.</li><li>• Straddle injuries</li><li>• rupture of bulbous urethra.</li><li>• sharp blow to the perineum.</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Presentation of bulbar urethral rupture:</li><li>• Presentation of bulbar urethral rupture:</li><li>• Blood at urethral meatus Not being able to pass urine Urine building up in the bladder (distension) Butterfly shaped perineal hematoma Diagnosis is made by retrograde urethrography Suprapubic cystostomy is performed Delayed urethroplasty (2-3 months later) is the surgical treatment of choice</li><li>• Blood at urethral meatus</li><li>• Not being able to pass urine</li><li>• Urine building up in the bladder (distension)</li><li>• Butterfly shaped perineal hematoma</li><li>• Diagnosis is made by retrograde urethrography</li><li>• Suprapubic cystostomy is performed</li><li>• Delayed urethroplasty (2-3 months later) is the surgical treatment of choice</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28 th edition pg 1540-1541</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28 th edition pg 1540-1541</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 30-year-old male is brought to the emergency department after sustaining a perineal injury during a bicycle accident. He is in considerable pain and has noted blood at the urethral meatus. He reports that he has not been able to pass urine since the accident and feels his abdomen is markedly distended. On examination, there is a large, butterfly-shaped hematoma present in the perineal region. What is most likely injured in this patient?", "options": [{"label": "A", "text": "Prostatic urethra", "correct": false}, {"label": "B", "text": "Penile urethra", "correct": false}, {"label": "C", "text": "Extra-peritoneal bladder rupture", "correct": false}, {"label": "D", "text": "Bulbous urethra", "correct": true}], "correct_answer": "D. Bulbous urethra", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture4_ZmAya0V.png"], "explanation_images": [], "explanation": "<p><strong>Ans. D) Bulbous urethra</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: The prostatic urethra is less likely to be injured by a straddle injury due to its protected location within the pelvic bones.</li><li>• Option A:</li><li>• prostatic urethra</li><li>• less likely to be injured by a straddle injury</li><li>• protected location</li><li>• pelvic bones.</li><li>• Option B: The penile urethra runs through the length of the penis and is injured in instrument trauma .</li><li>• Option B:</li><li>• penile urethra</li><li>• length of the penis</li><li>• injured in instrument trauma</li><li>• Option C: Bladder rupture will not present with blood at urethral meatus.</li><li>• Option C:</li><li>• Bladder rupture</li><li>• not</li><li>• blood at urethral meatus.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In the setting of a straddle injury with blood at the urethral meatus and inability to pass urine, the most likely site of urethral injury is the bulbar urethra. Diagnosis is typically confirmed by retrograde urethrography , and initial management may include a suprapubic cystostomy , followed by delayed urethroplasty for definitive repair.</li><li>➤ setting of a straddle injury with blood</li><li>➤ urethral meatus</li><li>➤ inability to pass urine,</li><li>➤ site of urethral injury is the bulbar urethra.</li><li>➤ Diagnosis</li><li>➤ retrograde urethrography</li><li>➤ initial management</li><li>➤ suprapubic cystostomy</li><li>➤ delayed urethroplasty</li><li>➤ definitive repair.</li><li>➤ Other types of urethral rupture: Posterior rupture</li><li>➤ Posterior rupture</li><li>➤ The incidence of posterior urethral injury in pelvic fracture is approximately 10%. They are most commonly seen after road traffic accidents. The site of injury is usually the prostate-membranous junction. Symptoms - retention of urine, blood at the meatus Digital rectal exam may reveal a floating prostate (Vermooten sign). Investigation : Diagnostic RGU is performed Management : Initial management is insertion of a suprapubic catheter. Delayed anastomotic urethroplasty has a high success rate in specialized centres</li><li>➤ The incidence of posterior urethral injury in pelvic fracture is approximately 10%.</li><li>➤ They are most commonly seen after road traffic accidents.</li><li>➤ The site of injury is usually the prostate-membranous junction.</li><li>➤ Symptoms - retention of urine, blood at the meatus</li><li>➤ Symptoms</li><li>➤ Digital rectal exam may reveal a floating prostate (Vermooten sign).</li><li>➤ Investigation : Diagnostic RGU is performed</li><li>➤ Investigation</li><li>➤ Management : Initial management is insertion of a suprapubic catheter. Delayed anastomotic urethroplasty has a high success rate in specialized centres</li><li>➤ Management</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28 th edition pg 1540-1542</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28 th edition pg 1540-1542</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 10-year-old male presents to the emergency department after sustaining a perineal injury during a bicycle accident. He is in distress and reports an inability to urinate. On examination, blood is noted at the urethral meatus, and the bladder is not palpable on abdominal examination. In the absence of any other visible injury and maintaining hemodynamic stability, what is the most appropriate next step in the management of this patient?", "options": [{"label": "A", "text": "Suprapubic aspiration", "correct": false}, {"label": "B", "text": "Insert a Foley’s catheter", "correct": false}, {"label": "C", "text": "Counsel and send home", "correct": false}, {"label": "D", "text": "Wait for bladder to fill and then perform supra-pubic cystostomy", "correct": true}], "correct_answer": "D. Wait for bladder to fill and then perform supra-pubic cystostomy", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/28/screenshot-2024-03-28-150420.png"], "explanation": "<p><strong>Ans. D) Wait for bladder to fill and then perform supra-pubic cystostomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Suprapubic aspiration could be considered if there is evidence of bladder distention and a need for immediate decompression ; however, the bladder is not palpable in this scenario, which suggests it is not distended.</li><li>• Option A:</li><li>• Suprapubic aspiration</li><li>• considered if there is evidence of bladder distention</li><li>• need for immediate decompression</li><li>• Option B: Inserting a Foley's catheter in the presence of a potential urethral injury could exacerbate the injury and is contraindicated until a urethral injury is ruled out.</li><li>• Option B:</li><li>• Inserting a Foley's catheter</li><li>• presence of a potential urethral injury</li><li>• exacerbate the injury</li><li>• Option C: Counseling and sending the patient home without addressing the inability to void and the potential for a urethral injury would be inappropriate and could lead to further complications.</li><li>• Option C:</li><li>• Counseling and sending the patient home</li><li>• without addressing</li><li>• inability to void</li><li>• potential for a urethral injury</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ When a patient present with blood at the urethral meatus and inability to void after a perineal injury , and the bladder is not palpable , the next step in management is to wait for the bladder to fill and reassess , avoiding the risk of aggravating a potential urethral injury (Option D).</li><li>➤ blood at the urethral meatus and inability to void after a perineal injury</li><li>➤ bladder is not palpable</li><li>➤ next step in management is to wait for the bladder to fill and reassess</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1540-1542</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1540-1542</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "The device in the image is used in the treatment of which pathology?", "options": [{"label": "A", "text": "Urethral rupture", "correct": false}, {"label": "B", "text": "Bladder stone", "correct": false}, {"label": "C", "text": "Stricture urethra", "correct": true}, {"label": "D", "text": "Non-gonococcal Urethritis", "correct": false}], "correct_answer": "C. Stricture urethra", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_croQ409.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Stricture urethra</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Urethral rupture: While a urethral rupture is a serious condition typically resulting from trauma , the primary treatment is not dilation . Instead, suprapubic catheter placement is indicated, depending on the rupture's severity and location.</li><li>• Option A: Urethral rupture:</li><li>• serious condition</li><li>• resulting from trauma</li><li>• primary treatment is not dilation</li><li>• Option B: Bladder stone: Bladder stones are typically treated with cystolitholapaxy (crushing and removal of stones using an endoscope) or cystolithotomy (surgical removal), not with a urethral dilator, which is not appropriate for this condition.</li><li>• Option B: Bladder stone:</li><li>• treated with cystolitholapaxy</li><li>• cystolithotomy</li><li>• Option D: Non-gonococcal Urethritis: Non-gonococcal urethritis, an inflammation of the urethra , is usually treated with antibiotics.</li><li>• Option D: Non-gonococcal Urethritis:</li><li>• inflammation of the urethra</li><li>• treated with antibiotics.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Lister’s urethral dilator is used to treat urethral strictures by dilating the narrowed portion of the urethra , a process which is effective for soft and short strictures and may be necessary repeatedly over time due to the nature of the condition.</li><li>➤ Lister’s urethral dilator</li><li>➤ treat urethral strictures by dilating the narrowed portion of the urethra</li><li>➤ process which is effective for soft and short strictures</li><li>➤ In the past, serial metal dilators were used under local anaesthesia . The complications include pain, fever, bleeding and false passage creation . Nowadays, dilatation is performed over a guidewire using serial plastic dilators . Dilatation is particularly effective for soft and short strictures. It is also indicated for unfit patients, patients refusing urethroplasty or those with multiple failed urethroplasties. Urethral dilatation rarely cures stricture and most patients require repeated dilations. Direct visual internal urethrotomy (DVIU): Performed using an optical urethrotome . The stricture is incised under visual control using a cold knife passed through the sheath of a rigid urethrotome. Alternatively, a laser fiber (holmium/thulium) can be used. DVIU is indicated for short, non-traumatic bulbar strictures but should not be used in the penile urethra or the sphincter active membranous urethra. Urethroplasty . There are two types of urethroplasty: anastomotic and augmentation. Anastomotic urethroplasty is performed for bulbar urethral traumatic strictures where there is a gap in the urethra. This involves dissection of the two ends of the urethra, spatulation and anastomosis. Augmentation urethroplasty is performed for non-traumatic and long strictures. In this type of urethroplasty the structured segment of urethra is incised and augmented with a patch (graft). Graft of choice is buccal mucosa.</li><li>➤ In the past, serial metal dilators were used under local anaesthesia . The complications include pain, fever, bleeding and false passage creation . Nowadays, dilatation is performed over a guidewire using serial plastic dilators . Dilatation is particularly effective for soft and short strictures. It is also indicated for unfit patients, patients refusing urethroplasty or those with multiple failed urethroplasties. Urethral dilatation rarely cures stricture and most patients require repeated dilations.</li><li>➤ serial metal dilators were used under local anaesthesia</li><li>➤ complications include pain, fever, bleeding and false passage creation</li><li>➤ dilatation is performed over a guidewire using serial plastic dilators</li><li>➤ Direct visual internal urethrotomy (DVIU): Performed using an optical urethrotome . The stricture is incised under visual control using a cold knife passed through the sheath of a rigid urethrotome. Alternatively, a laser fiber (holmium/thulium) can be used. DVIU is indicated for short, non-traumatic bulbar strictures but should not be used in the penile urethra or the sphincter active membranous urethra.</li><li>➤ Direct visual internal urethrotomy</li><li>➤ Performed using an optical urethrotome</li><li>➤ Urethroplasty . There are two types of urethroplasty: anastomotic and augmentation. Anastomotic urethroplasty is performed for bulbar urethral traumatic strictures where there is a gap in the urethra. This involves dissection of the two ends of the urethra, spatulation and anastomosis. Augmentation urethroplasty is performed for non-traumatic and long strictures. In this type of urethroplasty the structured segment of urethra is incised and augmented with a patch (graft). Graft of choice is buccal mucosa.</li><li>➤ Urethroplasty</li><li>➤ two types of urethroplasty: anastomotic and augmentation.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition page 1543.</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition page 1543.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 3-week-old male infant is brought to the pediatric clinic by his parents due to concerns about his urinary stream. The mother states that during diaper changes, she has noticed that her son's urinary stream seems to spray in multiple directions and that he appears uncomfortable during urination. On examination, you observe a good urinary flow, but the stream is misdirected. The infant has a normal voiding pattern without any signs of urinary tract infection, and his growth parameters are within normal limits. What is the most common congenital anomaly in urethra?", "options": [{"label": "A", "text": "Hypospadias", "correct": true}, {"label": "B", "text": "Epispadias", "correct": false}, {"label": "C", "text": "Double urethra", "correct": false}, {"label": "D", "text": "Posterior urethral valve", "correct": false}], "correct_answer": "A. Hypospadias", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Hypospadias</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Epispadias is a less common congenital abnormality where the urethral opening is located on the dorsal (upper) aspect of the penis. It's often associated with bladder exstrophy and is less common than hypospadias.</li><li>• Option B: Epispadias</li><li>• less common congenital abnormality</li><li>• urethral opening is located on the dorsal</li><li>• aspect of the penis.</li><li>• Option C: A double urethra, or urethral duplication, is an extremely rare congenital condition where there is a complete or partial duplication of the urethra.</li><li>• Option C: A double urethra,</li><li>• extremely rare congenital condition</li><li>• complete or partial duplication of the urethra.</li><li>• Option D: Posterior urethral valves are an obstructive congenital malformation in the male urethra , and while they are the most common cause of bladder outlet obstruction in neonates, they are not as common as hypospadias.</li><li>• Option D:</li><li>• Posterior urethral valves</li><li>• obstructive congenital malformation</li><li>• male urethra</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Hypospadias is the most common congenital urethral anomaly in boys , characterized by the ectopic location of the urethral meatus on the ventral aspect of the penis, and it can be addressed surgically to correct the meatus position and any associated chordee.</li><li>➤ Hypospadias</li><li>➤ most common congenital urethral anomaly in boys</li><li>➤ ectopic location of the urethral meatus on the ventral aspect of the penis,</li><li>➤ addressed surgically to correct the meatus position</li><li>➤ Hypospadias is a congenital malformation seen in 1 in 300 boys. The urethral opening lies on the ventral aspect of the penis anywhere from the proximal glans to the perineum in association with a ventral curvature (called a chordee) and a ventrally deficient foreskin leading to a dorsal ‘hooded’ prepuce.</li><li>➤ Hypospadias is a congenital malformation seen in 1 in 300 boys.</li><li>➤ The urethral opening lies on the ventral aspect of the penis anywhere from the proximal glans to the perineum in association with a ventral curvature (called a chordee) and a ventrally deficient foreskin leading to a dorsal ‘hooded’ prepuce.</li><li>➤ Types:</li><li>➤ Types:</li><li>➤ Glanular hypospadias: The ectopic meatus is placed on the glans penis, but proximal to the normal site of the external meatus, which is marked by a blind pit. Coronal hypospadias: The meatus is placed at the level of the coronal sulcus. Penile hypospadias: The meatus is on the underside of the penile shaft. Penoscrotal hypospadias: The meatus is at the level of the penoscrotal junction. Perineal hypospadias: This is a rare and severe abnormality. The scrotum is bifid, and urethra opens between its two halves. This is associated with undescended testis, micropenis and disorders of sexual development.</li><li>➤ Glanular hypospadias: The ectopic meatus is placed on the glans penis, but proximal to the normal site of the external meatus, which is marked by a blind pit.</li><li>➤ Glanular hypospadias:</li><li>➤ Coronal hypospadias: The meatus is placed at the level of the coronal sulcus.</li><li>➤ Coronal hypospadias:</li><li>➤ Penile hypospadias: The meatus is on the underside of the penile shaft.</li><li>➤ Penile hypospadias:</li><li>➤ Penoscrotal hypospadias: The meatus is at the level of the penoscrotal junction.</li><li>➤ Penoscrotal hypospadias:</li><li>➤ Perineal hypospadias: This is a rare and severe abnormality. The scrotum is bifid, and urethra opens between its two halves. This is associated with undescended testis, micropenis and disorders of sexual development.</li><li>➤ Perineal hypospadias:</li><li>➤ Treatment:</li><li>➤ Treatment:</li><li>➤ Hypospadias repair - Hypospadias repair aims to achieve the usual meatal location and a straight penis to facilitate micturition and ejaculation. Surgery for distal hypospadias is often for cosmetic reasons. This is usually treated by a tubularized incised plate urethroplasty. Proximal hypospadias with chordee needs surgical correction and may involve a two-stage repair. The first stage corrects the penile curvature and the second stage repairs the urethra. Circumcision should be avoided as preputial skin may be required for future repairs or revisions. Surgery for hypospadias is best performed by experts in hypospadias surgery and is typically undertaken before the age of 18 months.</li><li>➤ Hypospadias repair - Hypospadias repair aims to achieve the usual meatal location and a straight penis to facilitate micturition and ejaculation.</li><li>➤ Hypospadias repair</li><li>➤ Surgery for distal hypospadias is often for cosmetic reasons. This is usually treated by a tubularized incised plate urethroplasty.</li><li>➤ Proximal hypospadias with chordee needs surgical correction and may involve a two-stage repair. The first stage corrects the penile curvature and the second stage repairs the urethra.</li><li>➤ Circumcision should be avoided as preputial skin may be required for future repairs or revisions. Surgery for hypospadias is best performed by experts in hypospadias surgery and is typically undertaken before the age of 18 months.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28th edition pg 1540</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28th edition pg 1540</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 10-year-old boy presents with progressive phimosis and white, hard preputial skin, dysuria and ballooning on micturition. Identify the condition from the picture below which can lead to pan-urethral stricture:", "options": [{"label": "A", "text": "Peyronie disease", "correct": false}, {"label": "B", "text": "Bowen’s disease", "correct": false}, {"label": "C", "text": "Smegma", "correct": false}, {"label": "D", "text": "Balanitis xerotica obliterans (BXO)", "correct": true}], "correct_answer": "D. Balanitis xerotica obliterans (BXO)", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture4_uqE4bhb.png"], "explanation_images": [], "explanation": "<p><strong>Ans. D) Balanitis xerotica obliterans</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Peyronie's disease is characterized by the formation of fibrous plaques within the penile shaft , causing b, not typically associated with phimosis or urethral stricture.</li><li>• Option A: Peyronie's disease</li><li>• formation of fibrous plaques</li><li>• within the penile shaft</li><li>• Option B: Bowen’s disease refers to a form of squamous cell carcinoma in situ presenting as a chronic patchy, red, scaly plaque on the skin and is not associated with the penile changes described, such as progressive phimosis and urethral stricture.</li><li>• Option B: Bowen’s disease</li><li>• form of squamous cell carcinoma</li><li>• situ presenting as a chronic patchy, red, scaly plaque on the skin</li><li>• not associated with the penile changes</li><li>• Option C: Smegma is a substance composed of shed skin cells and oils that can accumulate under the foreskin but does not cause fibrosis or stricture ; it is usually a benign condition that can be managed with proper hygiene.</li><li>• Option C: Smegma</li><li>• substance composed of shed skin cells</li><li>• oils that can accumulate under the foreskin but does not cause fibrosis or stricture</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Balanitis xerotica obliterans , also known as lichen sclerosis, is characterized by fibrotic changes to the prepuce and glans penis , leading to phimosis and can be complicated by the development of pan-urethral stricture , often requiring surgical management.</li><li>➤ Balanitis xerotica obliterans</li><li>➤ lichen sclerosis,</li><li>➤ fibrotic changes to the prepuce and glans penis</li><li>➤ phimosis</li><li>➤ complicated by the development of pan-urethral stricture</li><li>➤ Balanitis xerotica obliterans (BXO)/ Lichen sclerosus: LS (previously known as balanitis xerotica obliterans [BXO]) is a condition characterised by fibrosis of the foreskin , resulting in phimosis. The glans may be involved and it presents as white patches . There can be a meatal stenosis and penile urethral stricture . The cause of the condition is unknown. The majority of studies suggest that it is an autoimmune condition or caused by infection. LS is usually diagnosed by visual inspection but a biopsy will confirm the diagnosis. Usually, circumcision is required, although some boys respond to topical corticosteroids. The strictures produced are typically long and difficult to treat. Common sites of stricture in LS are penile or panurethral.</li><li>➤ Balanitis xerotica obliterans (BXO)/ Lichen sclerosus: LS (previously known as balanitis xerotica obliterans [BXO]) is a condition characterised by fibrosis of the foreskin , resulting in phimosis. The glans may be involved and it presents as white patches . There can be a meatal stenosis and penile urethral stricture . The cause of the condition is unknown. The majority of studies suggest that it is an autoimmune condition or caused by infection.</li><li>➤ Balanitis xerotica obliterans</li><li>➤ Lichen sclerosus:</li><li>➤ characterised by fibrosis of the foreskin</li><li>➤ phimosis.</li><li>➤ glans may be involved and it presents as white patches</li><li>➤ meatal stenosis and penile urethral stricture</li><li>➤ LS is usually diagnosed by visual inspection but a biopsy will confirm the diagnosis. Usually, circumcision is required, although some boys respond to topical corticosteroids.</li><li>➤ The strictures produced are typically long and difficult to treat. Common sites of stricture in LS are penile or panurethral.</li><li>➤ Other causes of urethral stricture:</li><li>➤ Other causes of urethral stricture:</li><li>➤ Iatrogenic (post catheter and/or instrumentation); Sexually transmitted diseases (gonorrhoea); Post radiation; Traumatic; Idiopathic; Congenital.</li><li>➤ Iatrogenic (post catheter and/or instrumentation);</li><li>➤ Sexually transmitted diseases (gonorrhoea);</li><li>➤ Post radiation;</li><li>➤ Traumatic;</li><li>➤ Idiopathic;</li><li>➤ Congenital.</li><li>➤ Ref : Bailey and Love’s short practice of Surgery 28th edition pg 1542-43.</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of Surgery 28th edition pg 1542-43.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 55-year-old male presents to the emergency department with a rapidly progressing scrotal swelling, fever of 102°F, severe pain, and a foul-smelling serous discharge. He reports a sensation of crepitation upon palpation of the affected area. Physical examination reveals extensive erythema, ecchymosis, and areas of skin necrosis involving the scrotum and perineum. His medical history is significant for uncontrolled diabetes mellitus. Which of the following is the most likely diagnosis?", "options": [{"label": "A", "text": "Fournier’s gangrene", "correct": true}, {"label": "B", "text": "Epididymo-orchitis", "correct": false}, {"label": "C", "text": "Torsion testis", "correct": false}, {"label": "D", "text": "Carcinoma testis", "correct": false}], "correct_answer": "A. Fournier’s gangrene", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_QVeR2LZ.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. A) Fournier’s gangrene</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: This condition presents with pain and swelling of the scrotum , but it is usually unilateral and lacks the rapid progression and severe systemic symptoms of necrotizing fasciitis.</li><li>• Option B:</li><li>• condition presents with pain and swelling of the scrotum</li><li>• unilateral and lacks the rapid progression</li><li>• Option C: Testicular torsion presents with sudden, severe pain and swelling of the scrotum , but without systemic symptoms like fever or skin changes such as crepitus and necrosis . It is seen in teenage boys.</li><li>• Option C:</li><li>• Testicular torsion</li><li>• sudden, severe pain and swelling of the scrotum</li><li>• without systemic symptoms like fever or skin changes such as crepitus and necrosis</li><li>• Option D: Testicular cancer typically presents as a painless mass in the testis and does not cause the acute, severe symptoms or skin changes seen in this patient.</li><li>• Option D:</li><li>• Testicular cancer</li><li>• presents as a painless mass in the testis</li><li>• does not cause the acute, severe symptoms</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The appropriate diagnosis for a patient with rapid onset of scrotal swelling, fever, severe pain, and skin necrosis , especially in the setting of uncontrolled diabetes mellitus , is Fournier’s gangrene , a severe infection requiring urgent surgical intervention.</li><li>➤ appropriate diagnosis for a patient with rapid onset of scrotal swelling, fever, severe pain, and skin necrosis</li><li>➤ setting of uncontrolled diabetes mellitus</li><li>➤ Fournier’s gangrene</li><li>➤ severe infection requiring urgent surgical intervention.</li><li>➤ Fournier’s gangrene is an uncommon and nasty condition characterised by a polymicrobial infection of the soft tissues of the perineum, external genitalia and perianal region . It is a form of necrotising fasciitis . There is a rapid onset of gangrene leading to exposure of the scrotal contents.</li><li>➤ Fournier’s gangrene</li><li>➤ uncommon and nasty condition characterised by a polymicrobial infection of the soft tissues</li><li>➤ perineum, external genitalia and perianal region</li><li>➤ form of necrotising fasciitis</li><li>➤ The hallmark of Fournier’s gangrene is intense pain and tenderness in the genitalia.</li><li>➤ The clinical course usually progresses through the following phases:</li><li>➤ The clinical course usually progresses through the following phases:</li><li>➤ Prodromal symptoms of fever and lethargy for 2–7 days Intense genital pain usually associated with oedema of the overlying skin; pruritus may be present Increasing genital pain with progressive erythema of the overlying skin; Dusky appearance of the overlying skin; subcutaneous crepitation; Obvious gangrene of part of the genitalia; purulent discharge</li><li>➤ Prodromal symptoms of fever and lethargy for 2–7 days</li><li>➤ Intense genital pain usually associated with oedema of the overlying skin; pruritus may be present</li><li>➤ Increasing genital pain with progressive erythema of the overlying skin;</li><li>➤ Dusky appearance of the overlying skin; subcutaneous crepitation;</li><li>➤ Obvious gangrene of part of the genitalia; purulent discharge</li><li>➤ Ref : Bailey 28 th Ed. Pg 1573</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 1573</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 65-year-old male with a history of poorly controlled diabetes mellitus presents with a two-day history of fever, lethargy, and severe pain in the genital region. Physical examination reveals a scrotum with progressive erythema, a dusky discoloration of the overlying skin, crepitation on palpation, blackening of the tissue, and purulent discharge from scrotal wounds. What would be the best line of treatment for this patient?", "options": [{"label": "A", "text": "Broad spectrum antibiotics", "correct": false}, {"label": "B", "text": "IV fluids and supportive management", "correct": false}, {"label": "C", "text": "Surgical debridement", "correct": true}, {"label": "D", "text": "Orchidectomy", "correct": false}], "correct_answer": "C. Surgical debridement", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Surgical debridement</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Broad-spectrum antibiotics are a crucial part of the treatment for this condition but are not sufficient as monotherapy because they do not address the source of the infection – the necrotic tissue.</li><li>• Option A: Broad-spectrum antibiotics</li><li>• crucial part of the treatment for this condition</li><li>• not sufficient as monotherapy</li><li>• Option B: Intravenous fluids and supportive management are important for maintaining hemodynamic stability and are part of the overall management but are not the definitive treatment for the underlying condition.</li><li>• Option B: Intravenous fluids and supportive management</li><li>• maintaining hemodynamic stability</li><li>• part of the overall management</li><li>• Option D: Orchidectomy is inappropriate as the testes are spared in Fournier’s gangrene.</li><li>• Option D: Orchidectomy</li><li>• testes are spared in Fournier’s gangrene.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Fournier's gangrene is a surgical emergency that requires immediate debridement of necrotic tissues to prevent further spread of the infection.</li><li>➤ Fournier's gangrene</li><li>➤ surgical emergency</li><li>➤ requires immediate debridement of necrotic tissues</li><li>➤ spread of the infection.</li><li>➤ Management : Fournier's gangrene requires early and aggressive treatment if the patient is to survive . Treatment involves urgent surgical debridement of necrotic tissue in combination with early use of intravenous broad- spectrum antibiotics. Urgent wide surgical excision of the dead and infected tissue is essential , and the extent of the internal necrosis is typically much greater than the external appearances suggest, with extensive debridement often necessary. Urinary and faecal diversion may be necessary. Supportive care is essential because patients often become severely septic. Early review of the wounds is helpful to confirm that all dead tissue has been removed; when the infection has been controlled, vacuum-assisted dressing is helpful, if it is available. If the patient survives the acute episode, skin grafting is often necessary. Despite the best therapy, mortality rates as high as 50% are often reported.</li><li>➤ Management : Fournier's gangrene requires early and aggressive treatment if the patient is to survive . Treatment involves urgent surgical debridement of necrotic tissue in combination with early use of intravenous broad- spectrum antibiotics.</li><li>➤ Management</li><li>➤ Fournier's gangrene</li><li>➤ early and aggressive treatment if the patient is to survive</li><li>➤ Urgent wide surgical excision of the dead and infected tissue is essential , and the extent of the internal necrosis is typically much greater than the external appearances suggest, with extensive debridement often necessary. Urinary and faecal diversion may be necessary. Supportive care is essential because patients often become severely septic.</li><li>➤ Urgent wide surgical excision</li><li>➤ dead and infected tissue is essential</li><li>➤ Early review of the wounds is helpful to confirm that all dead tissue has been removed; when the infection has been controlled, vacuum-assisted dressing is helpful, if it is available. If the patient survives the acute episode, skin grafting is often necessary.</li><li>➤ Despite the best therapy, mortality rates as high as 50% are often reported.</li><li>➤ Ref : Bailey and Love’s Short Practice of surgery 28th edition pg 1573</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of surgery 28th edition pg 1573</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 52-year-old uncircumcised male presents to the clinic with a chronic, non-healing red patch on the shaft of his penis. He has a 30-year history of smoking one pack of cigarettes per day and has not been vaccinated against human papillomavirus (HPV). On physical examination, there is a well-demarcated erythematous plaque without evidence of invasive disease. He denies any pain or discomfort in the area but is concerned about the persistent nature of the lesion. A biopsy of the lesion is performed. Which of the following is the most likely diagnosis?", "options": [{"label": "A", "text": "Peyronie’s disease", "correct": false}, {"label": "B", "text": "Bowen’s disease", "correct": true}, {"label": "C", "text": "Bushke-Lowenstein’s disease", "correct": false}, {"label": "D", "text": "Penile papillomatosis", "correct": false}], "correct_answer": "B. Bowen’s disease", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Bowen’s disease</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Peyronie’s disease is characterized by the formation of fibrous plaques within the penile shaft , leading to abnormal curvature during erections, not erythematous patches.</li><li>• Option A: Peyronie’s disease</li><li>• characterized by the formation of fibrous plaques</li><li>• penile shaft</li><li>• abnormal curvature during erections,</li><li>• Option C: Bushke-Lowenstein’s disease or giant condyloma acuminatum is a verrucous carcinoma associated with HPV , typically presenting as a cauliflower-like growth rather than a red patch.</li><li>• Option C: Bushke-Lowenstein’s disease</li><li>• giant condyloma acuminatum</li><li>• verrucous carcinoma associated with HPV</li><li>• cauliflower-like growth</li><li>• Option D: Penile papillomatosis typically refers to benign papules found on the penis , often pearly penile papules , which do not carry malignant potential and do not appear as red plaques.</li><li>• Option D: Penile papillomatosis</li><li>• benign papules found on the penis</li><li>• pearly penile papules</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Bowen’s disease is a form of penile intraepithelial neoplasia , which presents as a chronic, well-demarcated red patch on the penis and can be associated with risk factors such as HPV infection and smoking.</li><li>➤ Bowen’s disease</li><li>➤ form of penile intraepithelial neoplasia</li><li>➤ presents as a chronic, well-demarcated red patch on the penis</li><li>➤ Risk factors for Ca Penis:</li><li>➤ Risk factors for Ca Penis:</li><li>➤ Circumcision soon after birth confers immunity against carcinoma of the penis. Later circumcision does not seem to have the same benefit, with the assumption that smegma is in some way carcinogenic. Infection with HPV types 16 and 18 is a risk factor, as are LS and smoking Phimosis and chronic balanoposthitis are known to be contributory factors Precancerous states include leukoplakia of the glans, which is similar to the condition seen on the tongue. Penile intraepithelial neoplasia (PeIN): PeIN is typically seen as a red cutaneous patch on the penis. When it occurs on the glans penis, it is known as erythroplasia of Queyrat; When it occurs on the shaft of the penis, it is called Bowen’s disease. There are several other benign causes of red patches on the penis; when there is clinical doubt as to the underlying diagnosis a biopsy is indicated. When the diagnosis of carcinoma in situ is confirmed, treatment is by means of topical 5-fluorouracil cream, CO2 laser ablation or surgical excision.</li><li>➤ Circumcision soon after birth confers immunity against carcinoma of the penis. Later circumcision does not seem to have the same benefit, with the assumption that smegma is in some way carcinogenic.</li><li>➤ Infection with HPV types 16 and 18 is a risk factor, as are LS and smoking</li><li>➤ Phimosis and chronic balanoposthitis are known to be contributory factors</li><li>➤ Precancerous states include leukoplakia of the glans, which is similar to the condition seen on the tongue.</li><li>➤ Penile intraepithelial neoplasia (PeIN): PeIN is typically seen as a red cutaneous patch on the penis. When it occurs on the glans penis, it is known as erythroplasia of Queyrat;</li><li>➤ When it occurs on the shaft of the penis, it is called Bowen’s disease.</li><li>➤ There are several other benign causes of red patches on the penis; when there is clinical doubt as to the underlying diagnosis a biopsy is indicated.</li><li>➤ When the diagnosis of carcinoma in situ is confirmed, treatment is by means of topical 5-fluorouracil cream, CO2 laser ablation or surgical excision.</li><li>➤ Ref : Bailey 28 th Ed. Pg 1552.</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 1552.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old male presents to the clinic with a slow-growing, cauliflower-like mass on the penile shaft that has been present for several months. He denies any pain associated with the lesion but is concerned about its progressive enlargement. He reports no history of sexually transmitted infections and has not had any prior treatment for this condition. Physical examination reveals a large exophytic lesion with a verrucous surface; however, there are no palpable inguinal lymph nodes. A biopsy of the lesion is consistent with a verrucous carcinoma. Which of the following is the most appropriate treatment for this patient?", "options": [{"label": "A", "text": "5 FU cream", "correct": false}, {"label": "B", "text": "CO2 Laser ablation", "correct": false}, {"label": "C", "text": "Partial penectomy", "correct": true}, {"label": "D", "text": "Partial penectomy with ilioinguinal lymphadenectomy", "correct": false}], "correct_answer": "C. Partial penectomy", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Partial penectomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: 5-fluorouracil (5 FU) cream is used topically for the treatment of superficial basal cell carcinomas and actinic keratoses . It is not the appropriate treatment for verrucous carcinoma.</li><li>• Option A: 5-fluorouracil (5 FU) cream</li><li>• topically for the treatment of superficial basal cell carcinomas and actinic keratoses</li><li>• Option B: CO2 laser ablation can be used for superficial lesions and for precise destruction of the lesion with minimal damage to surrounding tissues . However, given the locally invasive nature of verrucous carcinoma, CO2 laser ablation alone may not be adequate.</li><li>• Option B: CO2 laser ablation</li><li>• superficial lesions and for precise destruction of the lesion with minimal damage to surrounding tissues</li><li>• Option D: Partial penectomy with ilioinguinal lymphadenectomy might be considered for squamous cell carcinomas of the penis with suspected lymph node involvement. However, the Buschke–Löwenstein tumour typically does not metastasize to lymph nodes; therefore, lymphadenectomy is not indicated unless there is clinical or radiological evidence of nodal involvement.</li><li>• Option D: Partial penectomy with ilioinguinal lymphadenectomy</li><li>• squamous cell carcinomas of the penis with suspected lymph node involvement.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The appropriate treatment for a Buschke–Löwenstein tumour is surgical excision in the form of partial penectomy due to the locally invasive nature of verrucous carcinoma , without the need for lymphadenectomy in the absence of nodal involvement.</li><li>➤ appropriate treatment for a Buschke–Löwenstein tumour is surgical excision</li><li>➤ form of partial penectomy</li><li>➤ locally invasive nature of verrucous carcinoma</li><li>➤ without the need for lymphadenectomy in the absence of nodal involvement.</li><li>➤ Buschke –Löwenstein tumour : The Buschke–Löwenstein tumour is uncommon . It has the histological pattern of a verrucous carcinoma . It is locally destructive and invasive but appears not to spread to lymph nodes or to metastasise. Treatment is by surgical excision.</li><li>➤ Buschke –Löwenstein tumour : The Buschke–Löwenstein tumour is uncommon . It has the histological pattern of a verrucous carcinoma . It is locally destructive and invasive but appears not to spread to lymph nodes or to metastasise. Treatment is by surgical excision.</li><li>➤ Buschke –Löwenstein tumour</li><li>➤ uncommon</li><li>➤ histological pattern of a verrucous carcinoma</li><li>➤ Ref : Bailey 28 th Ed. Pg 1553</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 1553</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old male presents with lesions on glAns. Biopsy reveals moderately differentiated squamous cell CA of penis. Clinically no inguinal nodes are palpable. CECT reveals few unilateral enlarged inguinal nodes without pelvic lymph nodal enlargement. How will you manage the patient?", "options": [{"label": "A", "text": "Partial penectomy alone", "correct": false}, {"label": "B", "text": "Partial penectomy with Sentinel LN biopsy", "correct": false}, {"label": "C", "text": "Partial penectomy with Ilio-inguinal block dissection", "correct": false}, {"label": "D", "text": "Partial penectomy with 3 weeks of antibiotics post-op", "correct": true}], "correct_answer": "D. Partial penectomy with 3 weeks of antibiotics post-op", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Partial penectomy with 3 weeks of antibiotics post-op</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Partial penectomy alone may address the primary lesion but fails to evaluate or manage potential regional metastasis indicated by the enlarged inguinal nodes on CECT.</li><li>• Option A: Partial penectomy alone</li><li>• address the primary lesion</li><li>• fails to evaluate or manage potential regional metastasis</li><li>• Option B: Partial penectomy with sentinel lymph node biopsy could be considered for clinically non-palpable nodes. However, since CECT reveals enlarged nodes, a sentinel lymph node biopsy may not be the most appropriate next step.</li><li>• Option B: Partial penectomy with sentinel lymph node biopsy</li><li>• clinically non-palpable nodes.</li><li>• Option C: Partial penectomy with ilioinguinal block dissection is generally considered when there's clinical evidence of nodal involvement; however, in this case, given the possibility of infection-induced enlargement, immediate block dissection may not be warranted.</li><li>• Option C: Partial penectomy with ilioinguinal block dissection</li><li>• considered when there's clinical evidence of nodal involvement;</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In the presence of unilateral enlarged inguinal nodes without palpable nodes and no pelvic lymphadenopathy in penile cancer , the management should include partial penectomy followed by a course of antibiotics to address potential infection before considering further nodal management.</li><li>➤ presence of unilateral enlarged inguinal nodes without palpable nodes and no pelvic lymphadenopathy in penile cancer</li><li>➤ management</li><li>➤ partial penectomy</li><li>➤ course of antibiotics to address potential infection</li><li>➤ nodal management.</li><li>➤ Treatment of any associated enlarged inguinal lymph nodes should be delayed until at least 3 weeks after local treatment of the primary lesion . Enlargement caused by infection will usually show signs of subsiding with antibiotic treatment. For palpable nodes, ultrasound-guided fine-needle aspiration will confirm the diagnosis and a block dissection of both groins should be undertaken. The management of patients where the nodes are not palpable involves the use of sentinel lymph node biopsy (SLNB) followed by inguinal node dissection if the SLNB is positive. Management of the pelvic nodes is controversial, when they are involved in CT scanning, surgery probably has little role; however, when the iliac nodes are not enlarged in the presence of N2 disease, the options are observation, pelvic lymphadenectomy or radiotherapy. Chemotherapy is relatively ineffective and currently is reserved for palliation in those with metastatic disease.</li><li>➤ Treatment of any associated enlarged inguinal lymph nodes should be delayed until at least 3 weeks after local treatment of the primary lesion .</li><li>➤ Treatment</li><li>➤ associated enlarged inguinal lymph nodes</li><li>➤ delayed until at least 3 weeks</li><li>➤ local treatment of the primary lesion</li><li>➤ Enlargement caused by infection will usually show signs of subsiding with antibiotic treatment. For palpable nodes, ultrasound-guided fine-needle aspiration will confirm the diagnosis and a block dissection of both groins should be undertaken.</li><li>➤ The management of patients where the nodes are not palpable involves the use of sentinel lymph node biopsy (SLNB) followed by inguinal node dissection if the SLNB is positive.</li><li>➤ Management of the pelvic nodes is controversial, when they are involved in CT scanning, surgery probably has little role; however, when the iliac nodes are not enlarged in the presence of N2 disease, the options are observation, pelvic lymphadenectomy or radiotherapy. Chemotherapy is relatively ineffective and currently is reserved for palliation in those with metastatic disease.</li><li>➤ Ref : Bailey and Love 28 th Ed. Pg 1553.</li><li>➤ Ref</li><li>➤ : Bailey and Love 28 th Ed. Pg 1553.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old male presents with a penile deformity characterized by a dorsal curvature during erection and palpable penile plaques. His medical history is significant for Dupuytren’s contracture. He reports pain during erection but denies any difficulty with urination. His symptoms have been stable for the past two years. Surgical intervention is being considered. Which of the following procedures is indicated for the surgical correction of this patient’s condition?", "options": [{"label": "A", "text": "Piersey gold operation", "correct": false}, {"label": "B", "text": "Dennis brown operation", "correct": false}, {"label": "C", "text": "Nesbitt’s operation", "correct": true}, {"label": "D", "text": "Boari flap operation", "correct": false}], "correct_answer": "C. Nesbitt’s operation", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Nesbitt’s operation</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Piersey gold operation. Removal of scrotum along with total amputation of penis for penile cancers.</li><li>• Option A: Piersey gold operation.</li><li>• Removal of scrotum</li><li>• total amputation of penis</li><li>• Option B: Dennis brown operation is typically associated with hypospadias repair .</li><li>• Option B: Dennis brown operation</li><li>• associated with hypospadias repair</li><li>• Option D: Boari flap operation is a surgical reconstruction technique used for ureteric injuries, not Peyronie’s disease.</li><li>• Option D: Boari flap operation</li><li>• surgical reconstruction technique</li><li>• ureteric injuries,</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Nesbitts operation is the surgical procedure used for correcting the curvature associated with Peyronie’s disease by plicating the tunica albuginea opposite the side of the curvature.</li><li>➤ Nesbitts operation</li><li>➤ surgical procedure used for correcting the curvature associated with Peyronie’s disease</li><li>➤ plicating the tunica albuginea opposite the side of the curvature.</li><li>➤ The deformity is commonly dorsal (towards the abdomen) and the deformity may prevent penetrative sexual intercourse . While the etiology is uncertain, there is an association with Dupuytren’s contracture. The natural history of the condition is that it typically progresses for 18–24 months before stabilizing. During this active phase of the disease, surgery is not indicated; a variety of medical treatments have been tried, although none with any good evidence of benefit. The diagnosis is usually made on clinical examination but MRI may be helpful . Newer treatments include intralesional injections of collagenase clostridium histolyticum (Xiafex). Surgical correction can be performed in two ways. If the penis is of adequate length, it is possible to plicate the tunica albuginea on the side opposite to the maximum curvature. The plication can be done by Nesbit’s technique or a 16-dot technique. The second option involves an incision of the plaque and a bovine pericardial patch.</li><li>➤ The deformity is commonly dorsal (towards the abdomen) and the deformity may prevent penetrative sexual intercourse . While the etiology is uncertain, there is an association with Dupuytren’s contracture. The natural history of the condition is that it typically progresses for 18–24 months before stabilizing. During this active phase of the disease, surgery is not indicated; a variety of medical treatments have been tried, although none with any good evidence of benefit.</li><li>➤ deformity is commonly dorsal</li><li>➤ deformity may prevent penetrative sexual intercourse</li><li>➤ The diagnosis is usually made on clinical examination but MRI may be helpful .</li><li>➤ diagnosis is usually made on clinical examination but MRI may be helpful</li><li>➤ Newer treatments include intralesional injections of collagenase clostridium histolyticum (Xiafex).</li><li>➤ Surgical correction can be performed in two ways. If the penis is of adequate length, it is possible to plicate the tunica albuginea on the side opposite to the maximum curvature. The plication can be done by Nesbit’s technique or a 16-dot technique. The second option involves an incision of the plaque and a bovine pericardial patch.</li><li>➤ Ref : Bailey and Love’s Short Practice of surgery 28th edition pg 1550.</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of surgery 28th edition pg 1550.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 1-year-old boy is brought to the pediatric clinic for a routine check-up. On examination, the right testicle is not palpable in the scrotum. His growth parameters are appropriate for his age, and his medical history is unremarkable. Considering the management of undescended testes, which of the following statements is incorrect?", "options": [{"label": "A", "text": "Surgery for undescended testes does not significantly reduce the chances of development of testicular carcinoma", "correct": false}, {"label": "B", "text": "Approximately 70% of the undescended testis descend by 3 months of age", "correct": false}, {"label": "C", "text": "Risk of developing testicular malignancy is about 2 times more", "correct": true}, {"label": "D", "text": "Patients have normal secondary sexual characteristics", "correct": false}], "correct_answer": "C. Risk of developing testicular malignancy is about 2 times more", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Risk of developing testicular malignancy is about 2 times more</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: While orchidopexy improves the ability for earlier detection of testicular cancer by placing the testis in the scrotum , it does not significantly reduce the long-term risk of developing cancer.</li><li>• Option A:</li><li>• orchidopexy improves the ability for earlier detection of testicular cancer by placing the testis in the scrotum</li><li>• Option B: It is correct that approximately 70% of cryptorchid testes will descend spontaneously , usually by 3 months of age.</li><li>• Option B:</li><li>• correct that approximately 70%</li><li>• cryptorchid testes</li><li>• descend spontaneously</li><li>• Option D: Patients with a history of undescended testes often have normal secondary sexual characteristics unless there is associated hypogonadism or other underlying conditions.</li><li>• Option D:</li><li>• Patients with a history of undescended testes</li><li>• normal secondary sexual characteristics unless there is associated hypogonadism</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ While orchidopexy does not significantly decrease the incidence of testicular cancer in patients with undescended testes , it facilitates earlier detection of potential malignancies. Additionally, the risk of testicular cancer in these patients is approximately 5-10 times greater than in the general population.</li><li>➤ orchidopexy does not significantly decrease the incidence of testicular cancer</li><li>➤ patients with undescended testes</li><li>➤ facilitates earlier detection of potential malignancies.</li><li>➤ risk of testicular cancer</li><li>➤ approximately 5-10 times greater than in the general population.</li><li>➤ Undescended Testis</li><li>➤ Undescended Testis</li><li>➤ In undescended testis: The testis is arrested in some part of its path to the scrotum In Ectopic testis: The testis is abnormally placed outside its path Retractile testis: In infancy, 80% of inapparent testis are retractile testis and require no treatment Approximately 70–77% of cryptorchid testes will spontaneously descend, usually by 3 months of age More common in preterm, small for gestational age, LBW &amp; twin neonates More common on right side Secondary sexual characteristics are normal</li><li>➤ In undescended testis: The testis is arrested in some part of its path to the scrotum</li><li>➤ In Ectopic testis: The testis is abnormally placed outside its path</li><li>➤ Retractile testis: In infancy, 80% of inapparent testis are retractile testis and require no treatment</li><li>➤ Approximately 70–77% of cryptorchid testes will spontaneously descend, usually by 3 months of age</li><li>➤ More common in preterm, small for gestational age, LBW &amp; twin neonates</li><li>➤ More common on right side</li><li>➤ Secondary sexual characteristics are normal</li><li>➤ Ref : Bailey 28 th Ed. Pg 1558, 27 th Ed. Pg 1498-99.</li><li>➤ Ref</li><li>➤ :</li><li>➤ Bailey 28 th Ed. Pg 1558, 27 th Ed. Pg 1498-99.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 2-year-old boy is brought to the pediatrician for a wellness visit. The mother reports that the child's right testicle cannot be felt within the scrotum. On examination, the right testicle is palpable in the inguinal canal and does not descend into the scrotum with gentle pressure. Which of these is not a usual complication of undescended testes?", "options": [{"label": "A", "text": "Torsion", "correct": false}, {"label": "B", "text": "Increased risk of trauma", "correct": false}, {"label": "C", "text": "Direct inguinal hernia", "correct": true}, {"label": "D", "text": "Seminoma", "correct": false}], "correct_answer": "C. Direct inguinal hernia", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Direct inguinal hernia</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Testicular torsion is a potential complication of undescended testes due to the abnormal position of the testis , which may predispose it to rotate on the spermatic cord.</li><li>• Option A: Testicular torsion</li><li>• potential complication of undescended testes</li><li>• abnormal position of the testis</li><li>• Option B: Increased risk of trauma to the testis is observed when the testis is located in the inguinal canal where it can be more susceptible to injury.</li><li>• Option B: Increased risk of trauma</li><li>• testis is observed when the testis is located in the inguinal canal</li><li>• Option D: Seminoma is a type of testicular cancer that can occur with greater frequency in men with a history of undescended testes.</li><li>• Option D: Seminoma</li><li>• testicular cancer that can occur with greater frequency in men</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ A direct inguinal hernia is not a usual complication of undescended testes , whereas an indirect inguinal hernia , associated with a patent processus vaginalis , is frequently observed in these patients.</li><li>➤ direct inguinal hernia</li><li>➤ not a usual complication of undescended testes</li><li>➤ indirect inguinal hernia</li><li>➤ patent processus vaginalis</li><li>➤ Complications of incomplete descent:</li><li>➤ Complications of incomplete descent:</li><li>➤ Torsion of testis Epididymo-orchitis An associated indirect inguinal hernia is frequent due to patent processus vaginalis Atrophy Pain: A test is situated in the inguinal canal is often liable to trauma and give rise to pain in the groin Sterility: If the condition is bilateral Malignancy: Risk is 40 times more than a normally placed testis.</li><li>➤ Torsion of testis</li><li>➤ Epididymo-orchitis</li><li>➤ An associated indirect inguinal hernia is frequent due to patent processus vaginalis</li><li>➤ indirect</li><li>➤ Atrophy</li><li>➤ Pain: A test is situated in the inguinal canal is often liable to trauma and give rise to pain in the groin</li><li>➤ Sterility: If the condition is bilateral</li><li>➤ Malignancy: Risk is 40 times more than a normally placed testis.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28th edition Pg 1559.</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28th edition Pg 1559.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 4-month-old male infant presents with his parents for a routine pediatric visit. The child was born full-term with an uncomplicated perinatal history. On examination, the left testicle is not palpable in the scrotum, and the right testicle is in a normal position. There is no evidence of an inguinal hernia, and the infant is otherwise healthy with normal development milestones. At what age is it most appropriate to refer this patient for surgical intervention if the testicle remains non-palpable in the scrotum?", "options": [{"label": "A", "text": "6 months", "correct": true}, {"label": "B", "text": "12 months", "correct": false}, {"label": "C", "text": "24 months", "correct": false}, {"label": "D", "text": "36 months", "correct": false}], "correct_answer": "A. 6 months", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) 6 months</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B, C, D are significantly later than the recommended age for surgery. Surgical correction after the age of 12 months may result in a lower success rate for germ cell development normalization and increased risk of future complications.</li><li>• Option B, C, D are</li><li>• later than the recommended age for surgery.</li><li>• Surgical correction after the age of 12 months</li><li>• lower success rate for germ cell development normalization</li><li>• increased risk of future complications.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Orchiopexy for undescended testis is recommended at 6 months of age to optimize outcomes related to fertility and malignancy risk . This timing allows for potential normal germ cell development before histological changes may become irreversible.</li><li>➤ Orchiopexy</li><li>➤ undescended testis</li><li>➤ 6 months of age to optimize outcomes related to fertility and malignancy risk</li><li>➤ timing allows for potential normal germ cell</li><li>➤ Testicular descent is usually complete by the 30th week of gestation . At birth, 4% of full-term and 30% of premature boys have an undescended testis (UDT). In most pediatric centers, orchiopexy for unilateral undescended testis is done when patients have reached about 6 months of age. This early intervention may permit post- natal germ cell development to proceed normally In infants with congenital UDT, still undescended after 12 weeks of age, orchiopexy is recommended at 6 months of age before germ cell development becomes deranged For non-palpable testes under anaesthesia, diagnostic laparoscopy is recommended. If a testis is found during laparoscopy, the options are: 1: Laparoscopic orchidopexy preserving the vessels: the testis is dissected of a triangular pedicle containing the testicular vessels and the vas. 2: Laparoscopic one-stage Fowler–Stephens orchidopexy: vessels are divided and the testis is dissected of a pedicle of the vas and brought down in one stage. 3: Laparoscopic two-stage Fowler–Stephens orchiopexy: vessels are divided with clips but dissection of the testis is postponed for 6 months to allow for optimal development of collaterals.</li><li>➤ Testicular descent is usually complete by the 30th week of gestation . At birth, 4% of full-term and 30% of premature boys have an undescended testis (UDT).</li><li>➤ Testicular descent</li><li>➤ complete by the 30th week of gestation</li><li>➤ In most pediatric centers, orchiopexy for unilateral undescended testis is done when patients have reached about 6 months of age. This early intervention may permit post- natal germ cell development to proceed normally</li><li>➤ In infants with congenital UDT, still undescended after 12 weeks of age, orchiopexy is recommended at 6 months of age before germ cell development becomes deranged</li><li>➤ For non-palpable testes under anaesthesia, diagnostic laparoscopy is recommended. If a testis is found during laparoscopy, the options are: 1: Laparoscopic orchidopexy preserving the vessels: the testis is dissected of a triangular pedicle containing the testicular vessels and the vas. 2: Laparoscopic one-stage Fowler–Stephens orchidopexy: vessels are divided and the testis is dissected of a pedicle of the vas and brought down in one stage. 3: Laparoscopic two-stage Fowler–Stephens orchiopexy: vessels are divided with clips but dissection of the testis is postponed for 6 months to allow for optimal development of collaterals.</li><li>➤ 1: Laparoscopic orchidopexy preserving the vessels: the testis is dissected of a triangular pedicle containing the testicular vessels and the vas. 2: Laparoscopic one-stage Fowler–Stephens orchidopexy: vessels are divided and the testis is dissected of a pedicle of the vas and brought down in one stage. 3: Laparoscopic two-stage Fowler–Stephens orchiopexy: vessels are divided with clips but dissection of the testis is postponed for 6 months to allow for optimal development of collaterals.</li><li>➤ 1: Laparoscopic orchidopexy preserving the vessels: the testis is dissected of a triangular pedicle containing the testicular vessels and the vas.</li><li>➤ 2: Laparoscopic one-stage Fowler–Stephens orchidopexy: vessels are divided and the testis is dissected of a pedicle of the vas and brought down in one stage.</li><li>➤ 3: Laparoscopic two-stage Fowler–Stephens orchiopexy: vessels are divided with clips but dissection of the testis is postponed for 6 months to allow for optimal development of collaterals.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28th edition pg 257</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28th edition pg 257</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 3-year-old boy is brought to the pediatric clinic with concerns about an abnormally positioned testicle. The parents report that they have never noticed the testicle within the scrotum, and on examination, it is not palpable in the expected location. Instead, a firm, mobile mass is palpable just inferior and medial to the right superficial inguinal ring. What is the most common site of an ectopic testis?", "options": [{"label": "A", "text": "Inguinal canal", "correct": false}, {"label": "B", "text": "Superficial inguinal pouch", "correct": true}, {"label": "C", "text": "Perineum", "correct": false}, {"label": "D", "text": "Base of penis", "correct": false}], "correct_answer": "B. Superficial inguinal pouch", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Superficial inguinal pouch</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Inguinal canal. While undescended testes are often located within the inguinal canal, this is not an ectopic testis.</li><li>• Option A: Inguinal canal.</li><li>• undescended testes</li><li>• located within the inguinal canal,</li><li>• Option C: Perineum. An ectopic testis can be located here , but it is much less common than the superficial inguinal pouch .</li><li>• Option C: Perineum.</li><li>• ectopic testis</li><li>• located here</li><li>• much less common than the superficial inguinal pouch</li><li>• Option D: Base of penis. This is a possible ectopic location for a testis , but again, it is not as common as the superficial inguinal pouch .</li><li>• Option D: Base of penis.</li><li>• ectopic location for a testis</li><li>• not as common as the superficial inguinal pouch</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Most common site of an ectopic testis is the superficial inguinal pouch, which is just inferior and medial to the superficial inguinal ring .</li><li>➤ common site of an ectopic testis</li><li>➤ superficial inguinal pouch,</li><li>➤ inferior and medial to the superficial inguinal ring</li><li>➤ An ectopic testis is one that has ended up away from the normal path of descent. The commonest site is the superficial inguinal pouch, just inferior and medial to the superficial inguinal ring. Other rarer ectopic sites include the femoral triangle, root of the penis and perineum. MC site of undescended testis is high scrotal (60%) followed by inguinal canal (25%).</li><li>➤ An ectopic testis is one that has ended up away from the normal path of descent. The commonest site is the superficial inguinal pouch, just inferior and medial to the superficial inguinal ring. Other rarer ectopic sites include the femoral triangle, root of the penis and perineum.</li><li>➤ MC site of undescended testis is high scrotal (60%) followed by inguinal canal (25%).</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28th edition pg 1558-59</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28th edition pg 1558-59</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 16-year-old boy presents to the emergency department with sudden onset severe pain in his left scrotum since waking up this morning. On examination, the left testis is high riding, swollen, and tender. The cremasteric reflex is absent. Which of the following signs is NOT typically associated with torsion of the testis?", "options": [{"label": "A", "text": "Deming’s sign", "correct": false}, {"label": "B", "text": "Prehn sign", "correct": false}, {"label": "C", "text": "Orr-chair sign", "correct": true}, {"label": "D", "text": "Angell’s sign", "correct": false}], "correct_answer": "C. Orr-chair sign", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Orr-chair sign</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Deming’s sign. This sign indicates spasm of the cremaster muscle , which can cause the testis to rise higher in the scrotum , a feature seen in testicular torsion.</li><li>• Option A: Deming’s sign.</li><li>• spasm of the cremaster muscle</li><li>• cause the testis to rise higher in the scrotum</li><li>• Option B: Prehn sign. Prehn's sign is positive when lifting the testis relieves the pain , which is more commonly associated with epididymitis rather than torsion.</li><li>• Option B: Prehn sign.</li><li>• positive when lifting the testis relieves the pain</li><li>• Option D: Angell’s sign. This refers to the horizontal lie of the testis , which can be associated with torsion.</li><li>• Option D: Angell’s sign.</li><li>• horizontal lie of the testis</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Orr-chair sign is not associated with testicular torsion but is used for identifying a retractile testis.</li><li>➤ Orr-chair sign is not associated with testicular torsion</li><li>➤ used for identifying a retractile testis.</li><li>➤ Signs seen in Torsion testis:</li><li>➤ Demin's sign: Spasm of the cremaster muscle due to twisting of the spermatic cord causes the affected testis to be positioned higher than the normal testis Angel's sign: The testis on the normal side lies horizontally and lower. Prehn’s sign: Helps in differentiating acute epididymo-orchitis from torsion testis. On lifting the testis, pain in acute epididymo-orchitis reduces.</li><li>➤ Demin's sign: Spasm of the cremaster muscle due to twisting of the spermatic cord causes the affected testis to be positioned higher than the normal testis</li><li>➤ Demin's sign:</li><li>➤ Angel's sign: The testis on the normal side lies horizontally and lower.</li><li>➤ Angel's sign:</li><li>➤ Prehn’s sign: Helps in differentiating acute epididymo-orchitis from torsion testis. On lifting the testis, pain in acute epididymo-orchitis reduces.</li><li>➤ Prehn’s sign:</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28th edition pg 1559-1560</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28th edition pg 1559-1560</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "An 8-year-old boy presents to the emergency department with a one-hour history of severe right-sided scrotal pain. On examination, the right scrotum is swollen, and there is marked tenderness. Notably, the pain intensifies when the right testis is elevated. What is the optimal time frame from the onset of symptoms in which surgical exploration is indicated to maximize the chance of testicular salvage?", "options": [{"label": "A", "text": "2 hrs", "correct": false}, {"label": "B", "text": "6 hrs", "correct": true}, {"label": "C", "text": "12 hr", "correct": false}, {"label": "D", "text": "24 hrs", "correct": false}], "correct_answer": "B. 6 hrs", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) 6 hours</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Urgent surgical exploration within 6 hours of symptom onset is critical in cases of suspected testicular torsion to maximize the chances of testicular salvage.</li><li>➤ Urgent surgical exploration</li><li>➤ 6 hours of symptom onset</li><li>➤ critical in cases of suspected testicular torsion to maximize the chances of testicular salvage.</li><li>➤ The management of the case should be determined primarily on clinical grounds. While Doppler ultrasound scanning can confirm the absence of the blood supply to the affected testis, false-positive results can be seen so it is not routinely recommended. If there is any doubt as to the diagnosis, then urgent scrotal exploration is indicated. The typical window of opportunity for surgical intervention and testicular salvage is 6 hours from onset of pain . Therefore, early urological surgery consultation upon presentation may be critical even in the absence of confirmatory testing.</li><li>➤ The management of the case should be determined primarily on clinical grounds. While Doppler ultrasound scanning can confirm the absence of the blood supply to the affected testis, false-positive results can be seen so it is not routinely recommended. If there is any doubt as to the diagnosis, then urgent scrotal exploration is indicated.</li><li>➤ The typical window of opportunity for surgical intervention and testicular salvage is 6 hours from onset of pain . Therefore, early urological surgery consultation upon presentation may be critical even in the absence of confirmatory testing.</li><li>➤ The typical window of opportunity for surgical intervention and testicular salvage is 6 hours from onset of pain</li><li>➤ Intra-vaginal torsion occurs as a result of a combination of:</li><li>➤ Intra-vaginal torsion occurs as a result of a combination of:</li><li>➤ High investment of the tunica vaginalis, causing the testis to hang within the tunica like a clapper in a bell. This is the most common cause in adolescents and is typically a bilateral abnormality. Inversion of the testis: the testis is rotated so that it lies transversely or upside down. Separation of the epididymis from the body of the testis, permitting torsion of the testis on the pedicle that connects the testis with the epididymis.</li><li>➤ High investment of the tunica vaginalis, causing the testis to hang within the tunica like a clapper in a bell. This is the most common cause in adolescents and is typically a bilateral abnormality.</li><li>➤ Inversion of the testis: the testis is rotated so that it lies transversely or upside down.</li><li>➤ Separation of the epididymis from the body of the testis, permitting torsion of the testis on the pedicle that connects the testis with the epididymis.</li><li>➤ Ref : Bailey 18 th Ed. Pg 1561-62.</li><li>➤ Ref</li><li>➤ : Bailey 18 th Ed. Pg 1561-62.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 30-year-old male presents to the clinic with a painless swelling of the scrotum. On examination, the swelling is smooth, and transillumination test is positive. Which of the following statements is incorrect regarding the swelling?", "options": [{"label": "A", "text": "Abnormal collection of serous fluid in tunica vaginalis", "correct": false}, {"label": "B", "text": "It is not possible to get above the swelling on examination of the scrotum", "correct": true}, {"label": "C", "text": "Vaginal hydrocele is associated with 5% of the inguinal hernia", "correct": false}, {"label": "D", "text": "In congenital hydrocele processus vaginalis is patent and connects to the peritoneal cavity", "correct": false}], "correct_answer": "B. It is not possible to get above the swelling on examination of the scrotum", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/26/screenshot-2024-03-26-181610.png"], "explanation": "<p><strong>Ans. B) It is not possible to get above the swelling on examination of the scrotum</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: This is true ; a hydrocele is an accumulation of serous fluid within the tunica vaginalis.</li><li>• Option A:</li><li>• true</li><li>• Option C: This is true ; about 5% of inguinal hernias can be associated with a vaginal hydrocele.</li><li>• Option C:</li><li>• true</li><li>• Option D: This is also true ; a congenital hydrocele occurs when the processus vaginalis remains patent and fluid from the peritoneal cavity can enter it.</li><li>• Option D:</li><li>• true</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In the examination of a hydrocele , it is typically possible to palpate above the swelling in the scrotum, which helps differentiate it from other causes of scrotal swelling such as inguinal hernia .</li><li>➤ examination of a hydrocele</li><li>➤ possible to palpate above the swelling in the scrotum,</li><li>➤ helps differentiate it from other causes of scrotal swelling</li><li>➤ inguinal hernia</li><li>➤ Hydrocele</li><li>➤ Hydrocele</li><li>➤ A hydrocele is an abnormal collection of serous fluid in a part of the processus vaginalis, usually the tunica . Hydrocele fluid contains albumin and fibrinogen . If the contents of a hydrocele are allowed to drain into a collecting vessel, the liquid does not clot; however, the fluid coagulates if mixed with even a trace of blood that has been in contact with damaged tissue. About 5% of inguinal hernias are associated with a vaginal hydrocele on the same side. In congenital hydrocele, the processus vaginalis is patent and connects with the peritoneal cavity.</li><li>➤ A hydrocele is an abnormal collection of serous fluid in a part of the processus vaginalis, usually the tunica .</li><li>➤ hydrocele is an abnormal collection of serous fluid</li><li>➤ processus vaginalis,</li><li>➤ tunica</li><li>➤ Hydrocele fluid contains albumin and fibrinogen . If the contents of a hydrocele are allowed to drain into a collecting vessel, the liquid does not clot; however, the fluid coagulates if mixed with even a trace of blood that has been in contact with damaged tissue.</li><li>➤ Hydrocele fluid contains albumin and fibrinogen</li><li>➤ About 5% of inguinal hernias are associated with a vaginal hydrocele on the same side.</li><li>➤ In congenital hydrocele, the processus vaginalis is patent and connects with the peritoneal cavity.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1585</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1585</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 16-year-old boy presents to the andrology clinic with a complaint of testicular swelling and a sensation of heaviness that worsens with standing. On physical examination, with the patient standing, the testes feel like a 'bag of worms', and a cough impulse is noted. What is the most appropriate next step in the investigation of this condition?", "options": [{"label": "A", "text": "CT abdomen", "correct": false}, {"label": "B", "text": "CT pelvis", "correct": false}, {"label": "C", "text": "USG Doppler Scrotum", "correct": true}, {"label": "D", "text": "Angiogram", "correct": false}], "correct_answer": "C. USG Doppler Scrotum", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) USG Doppler Scrotum</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: CT abdomen. While a CT scan of the abdomen may be useful in diagnosing other conditions, it is not the first-line imaging study for the evaluation of a varicocele.</li><li>• Option A: CT abdomen.</li><li>• CT scan of the abdomen</li><li>• useful in diagnosing other conditions,</li><li>• Option B: CT pelvis. Similar to CT abdomen, a CT scan of the pelvis is not typically indicated in the initial assessment of a varicocele.</li><li>• Option B: CT pelvis.</li><li>• CT scan of the pelvis</li><li>• not typically indicated in the initial assessment of a varicocele.</li><li>• Option D: Angiogram It is performed in arterial disorders, not varicocele.</li><li>• Option D: Angiogram</li><li>• arterial disorders,</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The next step in the investigation of a patient with suspected varicocele , who presents with 'bag of worms' sensation and scrotal heaviness , is an ultrasound Doppler of the scrotum . This non-invasive imaging study helps in confirming the diagnosis and assessing the severity of the varicocele.</li><li>➤ investigation of a patient with suspected varicocele</li><li>➤ 'bag of worms' sensation and scrotal heaviness</li><li>➤ ultrasound Doppler of the scrotum</li><li>➤ non-invasive imaging study</li><li>➤ diagnosis and assessing the severity of the varicocele.</li><li>➤ Presentation :</li><li>➤ Presentation</li><li>➤ While most varicoceles are asymptomatic, those that are symptomatic tend to present with dragging discomfort that is worse on standing at the end of the day. When examined in the erect position, the scrotum on the affected side often hangs lower than normal. On palpation, with the patient standing, the varicose plexus feels like a bag of worms.</li><li>➤ While most varicoceles are asymptomatic, those that are symptomatic tend to present with dragging discomfort that is worse on standing at the end of the day.</li><li>➤ When examined in the erect position, the scrotum on the affected side often hangs lower than normal.</li><li>➤ On palpation, with the patient standing, the varicose plexus feels like a bag of worms.</li><li>➤ Investigation of choice : USG Doppler scrotum</li><li>➤ Investigation of choice</li><li>➤ Treatment — Treatment of choice is radiological embolization of testicular vein</li><li>➤ Treatment</li><li>➤ radiological embolization of testicular vein</li><li>➤ If fails, then Laparoscopic ligation of testicular vein above the inguinal ligament.</li><li>➤ If fails, then Laparoscopic ligation of testicular vein above the inguinal ligament.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1564</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1564</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient present with a history of dull, aching pain in the left scrotum and a physical examination that reveals a palpable 'bag of worms' consistent with varicocele. Varicoceles are more commonly found on the left side due to the anatomical drainage pattern of the left testicular vein into which of the following vessels?", "options": [{"label": "A", "text": "Hemiazygos vein", "correct": false}, {"label": "B", "text": "IVC", "correct": false}, {"label": "C", "text": "Inferior mesenteric vein", "correct": false}, {"label": "D", "text": "Renal vein", "correct": true}], "correct_answer": "D. Renal vein", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_ZQF1Q9H.jpg"], "explanation": "<p><strong>Ans. D) Renal vein</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Renal vein is the correct answer . The left testicular vein drains into the left renal vein . The angle at which the left testicular vein enters the left renal vein , along with the potential compression between the superior mesenteric artery and aorta (the 'nutcracker' effect), can lead to increased pressure in the vein and the development of a varicocele.</li><li>• Renal vein</li><li>• correct answer</li><li>• left testicular vein drains into the left renal vein</li><li>• angle at which the left testicular vein enters the left renal vein</li><li>• potential compression between the superior mesenteric artery and aorta</li><li>• lead to increased pressure</li><li>• vein and the development of a varicocele.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The left testicular vein drains into the left renal vein , which is associated with a higher incidence of varicocele on the left side due to increased venous pressure and anatomical compression factors.</li><li>➤ left testicular vein drains into the left renal vein</li><li>➤ higher incidence of varicocele on the left side due to increased venous pressure</li><li>➤ anatomical compression factors.</li><li>➤ Varicocele</li><li>➤ Varicocele</li><li>➤ It is the dilatation and increased tortuosity of testicular veins (pampiniform plexus), mostly results from defective valves in testicular veins , but renal vein can also be involved . Mostly present in adolescence or early adulthood. Occurs predominantly on the left side. This is because the right testicular vein joins the low pressure IVC (below the right renal vein), whereas the left testicular vein joins the left renal vein, in which venous pressure is higher. Left varicoceles are more common than right because: The ‘nutcracker’ effect that occurs when the left testicular vein gets trapped between the superior mesenteric artery and the aorta. This causes venous compression and testicular vein obstruction. Angulation (90 degrees) at the junction of the left testicular vein and the left renal vein also causes a high pressure in left testicular vein.</li><li>➤ It is the dilatation and increased tortuosity of testicular veins (pampiniform plexus), mostly results from defective valves in testicular veins , but renal vein can also be involved .</li><li>➤ dilatation and increased tortuosity of testicular veins</li><li>➤ defective valves in testicular veins</li><li>➤ renal vein can also be involved</li><li>➤ Mostly present in adolescence or early adulthood.</li><li>➤ present in adolescence or early adulthood.</li><li>➤ Occurs predominantly on the left side. This is because the right testicular vein joins the low pressure IVC (below the right renal vein), whereas the left testicular vein joins the left renal vein, in which venous pressure is higher.</li><li>➤ Left varicoceles are more common than right because: The ‘nutcracker’ effect that occurs when the left testicular vein gets trapped between the superior mesenteric artery and the aorta. This causes venous compression and testicular vein obstruction.</li><li>➤ Angulation (90 degrees) at the junction of the left testicular vein and the left renal vein also causes a high pressure in left testicular vein.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1564</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1564</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 20-year-old male presents with hard painless testicular swelling. On investigations Alpha fetoprotein is 3080. No abdominal lump is felt. USG shows testicular mass with uniform echotexture and small areas of necrosis. Surrounding structures are normal. What is the next best step?", "options": [{"label": "A", "text": "FNAC", "correct": false}, {"label": "B", "text": "Trucut biopsy", "correct": false}, {"label": "C", "text": "High inguinal orchidectomy", "correct": true}, {"label": "D", "text": "PET-CT", "correct": false}], "correct_answer": "C. High inguinal orchidectomy", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) High inguinal orchidectomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Fine-needle aspiration cytology (FNAC). FNAC is not typically used for the initial evaluation of testicular masses because it can potentially seed the tumor along the needle track.</li><li>• Option A: Fine-needle aspiration cytology (FNAC).</li><li>• not typically used for the initial evaluation of testicular masses</li><li>• Option B: Trucut biopsy. As with FNAC , a biopsy is not usually performed due to the risk of tumor seeding and because it may alter lymphatic drainage pathways.</li><li>• Option B: Trucut biopsy.</li><li>• FNAC</li><li>• biopsy is not usually performed due to the risk of tumor seeding</li><li>• may alter lymphatic drainage pathways.</li><li>• Option D: Positron emission tomography-computed tomography (PET-CT). While PET-CT may have a role in staging certain testicular tumors , it is not the initial step in the management of a suspected testicular cancer.</li><li>• Option D: Positron emission tomography-computed tomography (PET-CT).</li><li>• role in staging certain testicular tumors</li><li>• not the initial step in the management</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ High inguinal orchiectomy is the initial treatment step for suspected testicular tumors , providing both therapeutic and diagnostic benefits . Further management is guided by histological diagnosis and staging investigations post-orchiectomy.</li><li>➤ High inguinal orchiectomy</li><li>➤ initial treatment step for suspected testicular tumors</li><li>➤ both therapeutic and diagnostic benefits</li><li>➤ Testicular Tumours</li><li>➤ Testicular Tumours</li><li>➤ Testicular cancer is among the most common malignancies in young males Risk factors- cryptorchidism, family history of testicular cancer, and intratubular germ cell neoplasia. Most cases are germ cell tumours; others being stromal (Leydig cell) or sex cord (Sertoli cell) tumors. Germ cell tumours can be broadly divided into seminoma and nonseminoma germ cell tumours (NSGCTs). The majority of seminomas are classic (85%); the remainder are either anaplastic or spermatocytic seminoma. NSGCTs are further divided into embryonal carcinoma, yolk sac or endodermal sinus tumours, choriocarcinoma, teratoma, and mixed germ cell tumours. Any solid intratesticular mass is considered malignant unless proven otherwise. Initial treatment of suspected testicular tumour is high inguinal orchiectomy, which involves removal of the testicle and spermatic cord at the level of the inguinal ring. After radical orchiectomy, the patient should undergo disease staging, including cross-sectional, contrast-enhanced imaging of the abdomen and pelvis and chest imaging, either chest radiography in low-risk patients or cross-sectional chest imaging in patients with high-risk disease.</li><li>➤ Testicular cancer is among the most common malignancies in young males</li><li>➤ Testicular cancer</li><li>➤ most common malignancies in young males</li><li>➤ Risk factors- cryptorchidism, family history of testicular cancer, and intratubular germ cell neoplasia.</li><li>➤ Most cases are germ cell tumours; others being stromal (Leydig cell) or sex cord (Sertoli cell) tumors.</li><li>➤ Germ cell tumours can be broadly divided into seminoma and nonseminoma germ cell tumours (NSGCTs). The majority of seminomas are classic (85%); the remainder are either anaplastic or spermatocytic seminoma. NSGCTs are further divided into embryonal carcinoma, yolk sac or endodermal sinus tumours, choriocarcinoma, teratoma, and mixed germ cell tumours.</li><li>➤ The majority of seminomas are classic (85%); the remainder are either anaplastic or spermatocytic seminoma. NSGCTs are further divided into embryonal carcinoma, yolk sac or endodermal sinus tumours, choriocarcinoma, teratoma, and mixed germ cell tumours.</li><li>➤ The majority of seminomas are classic (85%); the remainder are either anaplastic or spermatocytic seminoma.</li><li>➤ NSGCTs are further divided into embryonal carcinoma, yolk sac or endodermal sinus tumours, choriocarcinoma, teratoma, and mixed germ cell tumours.</li><li>➤ Any solid intratesticular mass is considered malignant unless proven otherwise.</li><li>➤ Initial treatment of suspected testicular tumour is high inguinal orchiectomy, which involves removal of the testicle and spermatic cord at the level of the inguinal ring.</li><li>➤ After radical orchiectomy, the patient should undergo disease staging, including cross-sectional, contrast-enhanced imaging of the abdomen and pelvis and chest imaging, either chest radiography in low-risk patients or cross-sectional chest imaging in patients with high-risk disease.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28th edition pg 1569-1572</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28th edition pg 1569-1572</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these testicular tumors is highly malignant and metastasis commonly via hematogenous and lymphatic route?", "options": [{"label": "A", "text": "Seminoma", "correct": false}, {"label": "B", "text": "Teratoma", "correct": false}, {"label": "C", "text": "Choriocarcinoma", "correct": true}, {"label": "D", "text": "Leydig cell tumor", "correct": false}], "correct_answer": "C. Choriocarcinoma", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Choriocarcinoma</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Seminoma. While seminomas are a type of germ cell tumor , they typically metastasize via the lymphatic route , and hematogenous spread is less common.</li><li>• Option A: Seminoma.</li><li>• type of germ cell tumor</li><li>• metastasize via the lymphatic route</li><li>• Option B: Teratoma. Teratomas are germ cell tumors that consist of various tissue types , do not have the same rapid and widespread metastatic pattern as choriocarcinomas.</li><li>• Option B: Teratoma.</li><li>• germ cell tumors</li><li>• consist of various tissue types</li><li>• not have the same rapid</li><li>• widespread metastatic pattern as choriocarcinomas.</li><li>• Option D: Leydig cell tumor. Most Leydig cell tumors are benign and those that are malignant usually do not spread as aggressively as choriocarcinomas.</li><li>• Option D: Leydig cell tumor.</li><li>• Leydig cell tumors</li><li>• benign</li><li>• those that are malignant</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Choriocarcinoma is a highly malignant testicular tumor that metastasizes early via both lymphatic and hematogenous routes and is associated with elevated levels of HCG.</li><li>➤ Choriocarcinoma</li><li>➤ highly malignant testicular tumor</li><li>➤ metastasizes early via both lymphatic and hematogenous routes</li><li>➤ elevated levels of HCG.</li><li>➤ Seminomas metastasise mainly via the lymphatics and haematogenous spread is uncommon . The lymphatic drainage of the testes is to the para-aortic lymph nodes near the origin of the gonadal vessels. The contralateral para-aortic lymph nodes are sometimes involved by tumour spread, but the inguinal lymph nodes are affected only if the scrotal skin is involved. Teratomas consist of different tissues derived from ectoderm, endoderm and mesoderm. Immature components are often neuroectodermal or mesenchymal tissue, while more mature tissue is often cystic with epithelial differentiation or consists of smooth muscle, connective tissue or cartilage. All can metastasise. Choriocarcinoma. This is part of a testicular GCT in 25% of tumours in adults. It very seldom appears as the single tumour component. Choriocarcinoma is almost never seen in childhood. This tumour produces human chorionic gonadotropin (HCG), which can be detected in blood. This is a highly malignant tumor that metastasizes early via both the lymphatics and the bloodstream. Leydig cell : Most of these tumours are benign. Malignant transformation occurs in 10% and is related to increased size (&gt;5 cm).</li><li>➤ Seminomas metastasise mainly via the lymphatics and haematogenous spread is uncommon . The lymphatic drainage of the testes is to the para-aortic lymph nodes near the origin of the gonadal vessels.</li><li>➤ Seminomas metastasise</li><li>➤ lymphatics and haematogenous spread is uncommon</li><li>➤ The contralateral para-aortic lymph nodes are sometimes involved by tumour spread, but the inguinal lymph nodes are affected only if the scrotal skin is involved.</li><li>➤ Teratomas consist of different tissues derived from ectoderm, endoderm and mesoderm. Immature components are often neuroectodermal or mesenchymal tissue, while more mature tissue is often cystic with epithelial differentiation or consists of smooth muscle, connective tissue or cartilage. All can metastasise.</li><li>➤ Choriocarcinoma. This is part of a testicular GCT in 25% of tumours in adults. It very seldom appears as the single tumour component. Choriocarcinoma is almost never seen in childhood. This tumour produces human chorionic gonadotropin (HCG), which can be detected in blood. This is a highly malignant tumor that metastasizes early via both the lymphatics and the bloodstream.</li><li>➤ Leydig cell : Most of these tumours are benign. Malignant transformation occurs in 10% and is related to increased size (&gt;5 cm).</li><li>➤ Leydig cell</li><li>➤ Ref : Bailey 28 th Ed. Pg 1569-70.</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 1569-70.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 25-year-old male presents with painless testicular swelling, fever, and weight loss. Which of the following diagnostic interventions is contraindicated due to the risk of spreading the potential malignancy?", "options": [{"label": "A", "text": "USG scrotum", "correct": false}, {"label": "B", "text": "CT abdomen and pelvis", "correct": false}, {"label": "C", "text": "Chest X-ray", "correct": false}, {"label": "D", "text": "Trans-scrotal biopsy", "correct": true}], "correct_answer": "D. Trans-scrotal biopsy", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Trans scrotal biopsy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Ultrasound (USG) of the scrotum. This is indicated for evaluating testicular swellings and can differentiate between solid and cystic masses . It is a non-invasive and first-line imaging modality for testicular cancer.</li><li>• Option A: Ultrasound (USG) of the scrotum.</li><li>• evaluating testicular swellings and can differentiate between solid and cystic masses</li><li>• Option B: CT scan of the abdomen and pelvis. This is indicated for staging purposes to evaluate for the presence of retroperitoneal lymphadenopathy and other abdominal or pelvic metastases.</li><li>• Option B: CT scan of the abdomen and pelvis.</li><li>• staging purposes to evaluate for the presence of retroperitoneal lymphadenopathy</li><li>• Option C: Chest X-ray. Chest X-ray PA view can pick up cannonball metastases , if in doubt CT scan of the abdomen and pelvis and Thorax to be done.</li><li>• Option C: Chest X-ray.</li><li>• pick up cannonball metastases</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ A trans-scrotal biopsy is contraindicated in the evaluation of testicular cancer due to the risk of spreading cancer cells beyond the tunica albuginea , the natural barrier against tumor spread . Instead, high inguinal orchiectomy is the standard approach for obtaining a histopathological diagnosis.</li><li>➤ trans-scrotal biopsy is contraindicated in the evaluation of testicular cancer</li><li>➤ risk of spreading cancer cells beyond the tunica albuginea</li><li>➤ natural barrier against tumor spread</li><li>➤ Painless testicular swelling in a 25-year-male with a history of fever and weight loss amounts to a diagnosis of Malignant Testicular swelling, i.e., Testicular cancer. The diagnosis of testicular cancer includes history and physical examination of the both testes, abdomen examination to rule out paraaortic nodes. To confirm the histopathological evidence of testicular cancer, Orchidectomy in the form of High inguinal Orchiectomy is done. Trans scrotal biopsy is contraindicated*, as Tunica albuginea will be breached during biopsy. Since Tunica albuginea is a natural barrier to testicular cancer, following biopsy, this will be breached and extend into the scrotum . Before orchiectomy, Serum tumor markers specific for testicular cancers like AFP, LDH and Beta HCG to be quantified. If tumor markers are elevated, metastasis works up to be done, to rule out lung metastases and liver metastases and nodal metastases.</li><li>➤ Painless testicular swelling in a 25-year-male with a history of fever and weight loss amounts to a diagnosis of Malignant Testicular swelling, i.e., Testicular cancer.</li><li>➤ The diagnosis of testicular cancer includes history and physical examination of the both testes, abdomen examination to rule out paraaortic nodes.</li><li>➤ To confirm the histopathological evidence of testicular cancer, Orchidectomy in the form of High inguinal Orchiectomy is done.</li><li>➤ Trans scrotal biopsy is contraindicated*, as Tunica albuginea will be breached during biopsy. Since Tunica albuginea is a natural barrier to testicular cancer, following biopsy, this will be breached and extend into the scrotum .</li><li>➤ Trans scrotal biopsy is contraindicated*, as Tunica albuginea will be breached during biopsy. Since Tunica albuginea is a natural barrier to testicular cancer, following biopsy, this will be breached and extend into the scrotum</li><li>➤ Before orchiectomy, Serum tumor markers specific for testicular cancers like AFP, LDH and Beta HCG to be quantified.</li><li>➤ If tumor markers are elevated, metastasis works up to be done, to rule out lung metastases and liver metastases and nodal metastases.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1516-1520</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1516-1520</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Carcinoma of the prostate typically occurs in which lobe of the prostate?", "options": [{"label": "A", "text": "Anterior lobe", "correct": false}, {"label": "B", "text": "Posterior lobe", "correct": true}, {"label": "C", "text": "Lateral lobe", "correct": false}, {"label": "D", "text": "Median lobe", "correct": false}], "correct_answer": "B. Posterior lobe", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/26/screenshot-2024-03-26-182853.png"], "explanation": "<p><strong>Ans. B) Posterior lobe</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Posterior lobe is the correct answer. Prostate carcinomas most commonly occur in the posterior lobe of the prostate , which is the part of the prostate that can be felt during a digital rectal examination (DRE). This is the region where the majority of prostate cancers originate.</li><li>• Posterior lobe</li><li>• correct answer.</li><li>• Prostate carcinomas</li><li>• commonly occur in the posterior lobe of the prostate</li><li>• part of the prostate</li><li>• felt during a digital rectal examination</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Majority of prostate carcinomas typically occur in the posterior lobe/Peripheral zone of the prostate gland.</li><li>➤ Majority of prostate carcinomas</li><li>➤ posterior lobe/Peripheral zone of the prostate gland.</li><li>➤ Anatomical division</li><li>➤ Anatomical division</li><li>➤ Prostate has 5 lobes Anterior lobe − Is a small isthmus connecting the two lateral lobes in front of the urethra Posterior lobe - It connects the two lateral lobes behind the urethra. It lies behind the median lobe and the ejaculatory ducts. Carcinomas are most common in this lobe. Median lobe - Lies behind the upper part of the urethra, in front of the ejaculatory ducts just below the neck of the bladder. The mucous membrane just behind the internal urethral orifice presents a slight elevation, the uvula vesicae of the urinary bladder, caused by the median lobe of prostate. Benign hyperplasia of the prostate arises in this lobe. Lateral lobes - Lie one on each side of the urethra.</li><li>➤ Prostate has 5 lobes</li><li>➤ Prostate has 5 lobes</li><li>➤ Anterior lobe − Is a small isthmus connecting the two lateral lobes in front of the urethra</li><li>➤ Anterior lobe</li><li>➤ Posterior lobe - It connects the two lateral lobes behind the urethra. It lies behind the median lobe and the ejaculatory ducts. Carcinomas are most common in this lobe.</li><li>➤ Posterior lobe</li><li>➤ Median lobe - Lies behind the upper part of the urethra, in front of the ejaculatory ducts just below the neck of the bladder. The mucous membrane just behind the internal urethral orifice presents a slight elevation, the uvula vesicae of the urinary bladder, caused by the median lobe of prostate. Benign hyperplasia of the prostate arises in this lobe.</li><li>➤ Median lobe</li><li>➤ the uvula vesicae of the urinary bladder,</li><li>➤ Lateral lobes - Lie one on each side of the urethra.</li><li>➤ Lateral lobes</li><li>➤ McNeal’s Zones or Surgical division of Prostate</li><li>➤ McNeal’s Zones or Surgical division of Prostate</li><li>➤ Prostate has 3 distinct zones The peripheral zone (PZ) - accounts for 70% of volume of young adult prostate The central zone (CZ) - accounts for 25% The transition zone (TZ) - accounts for 5% Carcinoma of prostate arises most commonly in → the peripheral zone Benign prostatic hyperplasia originates in → the transition zone</li><li>➤ Prostate has 3 distinct zones</li><li>➤ Prostate has 3 distinct zones</li><li>➤ The peripheral zone (PZ) - accounts for 70% of volume of young adult prostate</li><li>➤ peripheral zone</li><li>➤ The central zone (CZ) - accounts for 25%</li><li>➤ central zone</li><li>➤ The transition zone (TZ) - accounts for 5%</li><li>➤ transition zone</li><li>➤ Carcinoma of prostate arises most commonly in → the peripheral zone</li><li>➤ Benign prostatic hyperplasia originates in → the transition zone</li><li>➤ Ref : Bailey and Love’s short practice of surgery 27th edition Pg 1456.</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 27th edition Pg 1456.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 72-year-old male presents with difficulty initiating urination and a decreased force of stream. He reports nocturia and a sensation of incomplete bladder emptying. These symptoms have progressively worsened over the past year. Based on his symptoms, he is likely experiencing benign prostatic hyperplasia (BPH). Which of the following statements regarding the management of BPH is incorrect?", "options": [{"label": "A", "text": "It is a common cause of significant lower urinary tract symptoms (LUTS) in men", "correct": false}, {"label": "B", "text": "It is the most common cause of bladder outflow obstruction (BOO) in men &gt;70 years of age", "correct": false}, {"label": "C", "text": "It is seen in men above 50 years of age", "correct": false}, {"label": "D", "text": "5-alpha reductase inhibitors and alpha-adrenergic agonists are used for the treatment of this condition", "correct": true}], "correct_answer": "D. 5-alpha reductase inhibitors and alpha-adrenergic agonists are used for the treatment of this condition", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) 5-alpha reductase inhibitors and alpha-adrenergic agonists are used for the treatment of this condition.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: This is true ; BPH commonly causes LUTS in men.</li><li>• Option A:</li><li>• true</li><li>• Option B: This is also true ; BPH is the most common cause of BOO in elderly men.</li><li>• Option B:</li><li>• true</li><li>• Option C: This is true ; BPH is seen in men above 50 years of age, and the incidence increases with age.</li><li>• Option C:</li><li>• true</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The medical treatment for BPH includes 5-alpha reductase inhibitors , which shrink the prostate , and alpha-adrenergic blockers , which relax smooth muscle in the prostate to improve urinary flow . Alpha-adrenergic agonists are not used in the treatment of BPH and would be contraindicated as they would exacerbate urinary retention.</li><li>➤ medical treatment for BPH includes 5-alpha reductase inhibitors</li><li>➤ shrink the prostate</li><li>➤ alpha-adrenergic blockers</li><li>➤ relax smooth muscle in the prostate to improve urinary flow</li><li>➤ Treatment of BPH:</li><li>➤ Treatment of BPH:</li><li>➤ Medical : 5-alpha reductase inhibitors (Dutasteride) and alpha-adrenergic blockers (Tamsulosin) Surgical : Transurethral resection of prostate (TURP)</li><li>➤ Medical : 5-alpha reductase inhibitors (Dutasteride) and alpha-adrenergic blockers (Tamsulosin)</li><li>➤ Medical</li><li>➤ Surgical : Transurethral resection of prostate (TURP)</li><li>➤ Surgical</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28th edition pg 1522</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28th edition pg 1522</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 68-year-old man presents with lower urinary tract symptoms. He reports increased frequency and urgency of urination, especially at night. However, he also mentions that he has to strain during urination. Which of the following symptoms is not predominantly associated with bladder storage problems?", "options": [{"label": "A", "text": "Straining", "correct": true}, {"label": "B", "text": "Frequency", "correct": false}, {"label": "C", "text": "Urgency", "correct": false}, {"label": "D", "text": "Nocturia", "correct": false}], "correct_answer": "A. Straining", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_CfcG6ND.jpg"], "explanation": "<p><strong>Ans. A) Straining</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Frequency. Increased frequency of urination is a classic storage symptom , often seen in conditions like overactive bladder or urinary tract infections.</li><li>• Option B: Frequency.</li><li>• Increased frequency of urination</li><li>• classic storage symptom</li><li>• Option C: Urgency. This is a hallmark symptom of storage issues and is commonly seen in overactive bladder syndrome.</li><li>• Option C: Urgency.</li><li>• hallmark symptom of storage issues</li><li>• Option D: Nocturia. Nocturia, or nighttime urination, is considered a storage issue and can be due to various causes , including reduced bladder capacity or nocturnal polyuria.</li><li>• Option D: Nocturia.</li><li>• nighttime urination,</li><li>• storage issue and can be due to various causes</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Straining to void is not a symptom of bladder storage problems but rather indicative of voiding difficulties , which could be due to conditions such as bladder outlet obstruction . Storage symptoms primarily include frequency, urgency, and nocturia.</li><li>➤ Straining to void</li><li>➤ not a symptom of bladder storage problems</li><li>➤ indicative of voiding difficulties</li><li>➤ conditions such as bladder outlet obstruction</li><li>➤ Storage symptoms</li><li>➤ frequency, urgency, and nocturia.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28th edition pg 1459</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28th edition pg 1459</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 70-year-old man presents with symptoms of benign prostatic hyperplasia. Which of these is not an indication to perform TURP?", "options": [{"label": "A", "text": "Acute retention", "correct": false}, {"label": "B", "text": "Residual urine &gt; 200 ml", "correct": false}, {"label": "C", "text": "Increased frequency", "correct": true}, {"label": "D", "text": "Bladder diverticuli", "correct": false}], "correct_answer": "C. Increased frequency", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Increased frequency</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Acute urinary retention. This is an indication for TURP when it is caused by BPH and cannot be managed medically.</li><li>• Option A: Acute urinary retention.</li><li>• indication for TURP</li><li>• Option B: Residual urine volume greater than 200 mL. Significant post-void residual urine volume indicates inadequate bladder emptying and can be an indication for TURP.</li><li>• Option B: Residual urine volume greater than 200 mL.</li><li>• post-void residual urine volume</li><li>• inadequate bladder emptying</li><li>• Option D: Presence of bladder diverticula. Diverticula can be complications of longstanding BPH due to high-pressure voiding , and their presence can be an indication for TURP.</li><li>• Option D: Presence of bladder diverticula.</li><li>• Diverticula</li><li>• complications of longstanding BPH due to high-pressure voiding</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ TURP is considered when a patient experiences complications of BPH , such as urinary retention, significant post-void residual urine, bladder stones, recurrent urinary tract infections , or bladder diverticula . Increased urinary frequency alone is not typically an indication for TURP.</li><li>➤ TURP</li><li>➤ patient experiences complications of BPH</li><li>➤ urinary retention, significant post-void residual urine, bladder stones, recurrent urinary tract infections</li><li>➤ bladder diverticula</li><li>➤ Increased urinary frequency</li><li>➤ not typically an indication for TURP.</li><li>➤ Indications for prostatectomy:</li><li>➤ Indications for prostatectomy:</li><li>➤ Acute retention Chronic retention and renal impairment: a residual urine of 200 mL or more, hydroureter or hydronephrosis demonstrated on ultrasound, uraemic manifestations and abnormal renal function (accounts for 15% of prostatectomies). Complications of Bladder outlet obstruction: stone, infection and diverticulum formation. Haemorrhage: these patients present with recurrent haematuria with no obvious cause and a very vascular prostate can be seen on cystoscopy. Elective prostatectomy for severe symptoms: this accounts for about 60% of prostatectomies. Frequency alone is not a strong indication for prostatectomy.</li><li>➤ Acute retention</li><li>➤ Chronic retention and renal impairment: a residual urine of 200 mL or more, hydroureter or hydronephrosis demonstrated on ultrasound, uraemic manifestations and abnormal renal function (accounts for 15% of prostatectomies).</li><li>➤ Complications of Bladder outlet obstruction: stone, infection and diverticulum formation.</li><li>➤ Haemorrhage: these patients present with recurrent haematuria with no obvious cause and a very vascular prostate can be seen on cystoscopy.</li><li>➤ Elective prostatectomy for severe symptoms: this accounts for about 60% of prostatectomies. Frequency alone is not a strong indication for prostatectomy.</li><li>➤ Elective prostatectomy for severe symptoms: this accounts for about 60% of prostatectomies. Frequency alone is not a strong indication for prostatectomy.</li><li>➤ The natural progression of outflow obstruction is variable and rarely gets worse after 10 years. Severe symptoms not responding to drug therapy, a low maximum flow rate (&lt;10 mL/s) and an increased residual volume of urine (100–250 mL) are relatively strong indications for operative treatment.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28th edition pg 1527</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28th edition pg 1527</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "An 80-year-old patient with benign prostatic hypertrophy complained of dizziness, nausea, vomiting after resection of large prostate by TURP. What is the most probable cause?", "options": [{"label": "A", "text": "Anemia due to blood loss", "correct": false}, {"label": "B", "text": "Water intoxication", "correct": true}, {"label": "C", "text": "Glycine toxicity", "correct": false}, {"label": "D", "text": "Hypoglycemia", "correct": false}], "correct_answer": "B. Water intoxication", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Water intoxication</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Anemia due to blood loss. Although blood loss can occur during TURP and cause symptoms like dizziness , it would not typically cause nausea and vomiting.</li><li>• Option A: Anemia due to blood loss.</li><li>• blood loss can occur during TURP</li><li>• cause symptoms like dizziness</li><li>• Option C: Glycine toxicity. Glycine is often used as an irrigant during TURP , and while toxicity can occur , it usually presents with visual disturbances or encephalopathy. It's less likely to cause nausea and vomiting alone.</li><li>• Option C: Glycine toxicity.</li><li>• used as an irrigant during TURP</li><li>• toxicity can occur</li><li>• visual disturbances or encephalopathy.</li><li>• Option D: Hypoglycemia. There is no direct link between hypoglycemia and TURP . Hypoglycemia would not typically be expected as a complication of this procedure unless there was a preexisting condition or medication interaction.</li><li>• Option D: Hypoglycemia.</li><li>• no direct link between hypoglycemia</li><li>• TURP</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Water intoxication , or TURP syndrome , can occur postoperatively due to the absorption of irrigation fluids . This can lead to hyponatremia and present with symptoms of nausea, vomiting, confusion, and dizziness . Treatment typically involves fluid restriction and careful management of electrolyte balance.</li><li>➤ Water intoxication</li><li>➤ TURP syndrome</li><li>➤ postoperatively due to the absorption of irrigation fluids</li><li>➤ lead to hyponatremia and present with symptoms of nausea, vomiting, confusion, and dizziness</li><li>➤ Absorption of water into the circulation at the time of TURP can give rise to congestive cardiac failure, hyponatremia and haemolysis. Patient presents with confusion and other cerebral events often mimicking a stroke. The treatment consists of fluid restriction.</li><li>➤ Absorption of water into the circulation at the time of TURP can give rise to congestive cardiac failure, hyponatremia and haemolysis.</li><li>➤ Patient presents with confusion and other cerebral events often mimicking a stroke.</li><li>➤ The treatment consists of fluid restriction.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28th edition pg 1530</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28th edition pg 1530</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In performing transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH), maintaining urinary continence post-procedure is crucial. Which anatomical landmark signifies the limit of inferior resection in TURP to preserve the external sphincter mechanism and ensure continence?", "options": [{"label": "A", "text": "Internal sphincter", "correct": false}, {"label": "B", "text": "Bladder neck", "correct": false}, {"label": "C", "text": "Verumontanum", "correct": true}, {"label": "D", "text": "Ejaculatory duct", "correct": false}], "correct_answer": "C. Verumontanum", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Verumontanum</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Internal sphincter. The internal sphincter is not the landmark used to determine the limit of TURP ; it is located at the bladder neck and not usually visible during the procedure.</li><li>• Option A: Internal sphincter.</li><li>• not the landmark used to determine the limit of TURP</li><li>• Option B: Bladder neck. Resection typically begins at the bladder neck , but this is not the landmark for the limit of resection.</li><li>• Option B: Bladder neck.</li><li>• Resection</li><li>• begins at the bladder neck</li><li>• Option D: Ejaculatory duct. The ejaculatory ducts are located proximal to the verumontanum , within the central zone of the prostate , and are not a landmark for the resection limit in TURP.</li><li>• Option D: Ejaculatory duct.</li><li>• located proximal to the verumontanum</li><li>• central zone of the prostate</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The verumontanum is the anatomical landmark that marks the proximal margin of the external sphincter . During TURP , resection should not extend beyond the verumontanum to avoid damaging the external sphincter and causing incontinence.</li><li>➤ verumontanum</li><li>➤ anatomical landmark</li><li>➤ marks the proximal margin of the external sphincter</li><li>➤ TURP</li><li>➤ resection should not extend beyond the verumontanum</li><li>➤ avoid damaging the external sphincter</li><li>➤ causing incontinence.</li><li>➤ “Incontinence is rare after BPH surgery ; however, it is inevitable if the external sphincter mechanism is damaged. The bladder neck is rendered incompetent by any prostatectomy and, therefore, an intact distal sphincter mechanism is essential for continence. The verumontanum marks the proximal margin of the external sphincter.”</li><li>➤ “Incontinence is rare after BPH surgery</li><li>➤ inevitable if the external sphincter mechanism is damaged.</li><li>➤ Ref : Bailey 28 th Ed. Pg 1530</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 1530</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 65-year-old man with prostate cancer has a magnetic resonance imaging (MRI) scan that reveals the tumor has extended beyond the prostatic capsule and involves the seminal vesicles. According to the TNM classification, Infiltration of Ca Prostate and seminal vesicles is categorised as:", "options": [{"label": "A", "text": "T3a", "correct": false}, {"label": "B", "text": "T3b", "correct": true}, {"label": "C", "text": "T3c", "correct": false}, {"label": "D", "text": "T4a", "correct": false}], "correct_answer": "B. T3b", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) T3b</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: T3a. This classification indicates extracapsular extension of the tumor without seminal vesicle invasion .</li><li>• Option A: T3a.</li><li>• indicates extracapsular extension</li><li>• tumor without seminal vesicle invasion</li><li>• Option C: T3c. There is no T3c category in the TNM classification for prostate cancer .</li><li>• Option C: T3c.</li><li>• no T3c category in the TNM classification for prostate cancer</li><li>• Option D: T4a. This classification is used when the tumor has invaded adjacent structures other than seminal vesicles , such as the bladder neck, external sphincter, or rectum.</li><li>• Option D: T4a.</li><li>• used when the tumor has invaded adjacent structures other than seminal vesicles</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The educational objective is to understand the TNM staging system for prostate cancer . T3b signifies that the cancer has spread to the seminal vesicles. This staging is critical for determining the appropriate treatment plan and prognosis for prostate cancer patients.</li><li>➤ understand the TNM staging system for prostate cancer</li><li>➤ T3b signifies that the cancer has spread to the seminal vesicles.</li><li>➤ T1 - Incidentally diagnosed [After TURP- T1a if cancer in &lt;5% of specimen or T1b if &gt;5% specimen, elevated PSA- T1c]</li><li>➤ T1</li><li>➤ T2 - Limited to Prostate</li><li>➤ T2</li><li>➤ T3 tumour extends through the capsule :</li><li>➤ T3 tumour extends through the capsule</li><li>➤ T3a, uni- or bilateral extension; T3b, seminal vesicle extension.</li><li>➤ T3a, uni- or bilateral extension;</li><li>➤ T3b, seminal vesicle extension.</li><li>➤ T4 is a tumour that is fixed or invading adjacent structures other than seminal vesicles – levator muscles, external sphincter, rectum or pelvic side wall.</li><li>➤ T4 is a tumour that is fixed or invading adjacent structures other than seminal vesicles</li><li>➤ Ref : Bailey 28 th Ed. Pg 1533</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 1533</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 60-year-old man with a confirmed diagnosis of prostate cancer is being evaluated for the extent of local disease. The patient's PSA level is elevated, and a digital rectal examination suggests hard and nodular prostate. Which imaging modality is considered the most accurate for local staging of prostate cancer?", "options": [{"label": "A", "text": "PET CT", "correct": false}, {"label": "B", "text": "TRUS", "correct": false}, {"label": "C", "text": "MRI", "correct": true}, {"label": "D", "text": "Cystoscopy", "correct": false}], "correct_answer": "C. MRI", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) MRI</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: PET CT. While PET CT is useful in the detection of metastatic disease , it is not the most accurate modality for local staging of prostate cancer.</li><li>• Option A: PET CT.</li><li>• useful in the detection of metastatic disease</li><li>• Option B: Transrectal ultrasound (TRUS). TRUS is used for guiding biopsies and can visualize the prostate; however, it is less accurate than MRI for local staging.</li><li>• Option B: Transrectal ultrasound (TRUS).</li><li>• used for guiding biopsies and can visualize the prostate;</li><li>• Option D: Cystoscopy. Cystoscopy allows visualization of the bladder and urethra but does not provide detailed information on the prostate gland's internal structure or extent of cancer.</li><li>• Option D: Cystoscopy.</li><li>• visualization of the bladder and urethra</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Multi-parametric MRI is the most accurate imaging modality for local staging of prostate cancer . It provides detailed visualization of the prostate and surrounding tissues , which is critical for determining the appropriate treatment plan.</li><li>➤ Multi-parametric MRI</li><li>➤ most accurate imaging modality for local staging</li><li>➤ prostate cancer</li><li>➤ visualization of the prostate and surrounding tissues</li><li>➤ MRI with a high-tesla magnet (1.5–3 T) is the most accurate method of staging local disease . mpMRI (multi-parametric) is used preoperatively to assess pelvic lymph nodes as well as local stage, although the sensitivity of mpMRI to detect small areas of capsular spread is limited, even in the best hands. As well as preoperative staging, mpMRI plays an important role in active surveillance and localisation of recurrent prostate cancer after surgery. Low-grade tumours are frequently not seen on MRI and are often clinically insignificant. TRUS scanning can also be used to stage prostate cancer. Locally extensive disease (T2) can be diagnosed with increased sensitivity by TRUS compared with rectal examination, but many tumours will still be missed. This problem remains a real one in screening for early prostate cancer; in comparison with breast cancer, with mammography detecting 70–80% of tumours, TRUS plus rectal examination and measurement of PSA will detect only 30–50% of cancers.</li><li>➤ MRI with a high-tesla magnet (1.5–3 T) is the most accurate method of staging local disease . mpMRI (multi-parametric) is used preoperatively to assess pelvic lymph nodes as well as local stage, although the sensitivity of mpMRI to detect small areas of capsular spread is limited, even in the best hands. As well as preoperative staging, mpMRI plays an important role in active surveillance and localisation of recurrent prostate cancer after surgery.</li><li>➤ MRI with a high-tesla magnet</li><li>➤ most accurate method of staging local disease</li><li>➤ Low-grade tumours are frequently not seen on MRI and are often clinically insignificant. TRUS scanning can also be used to stage prostate cancer. Locally extensive disease (T2) can be diagnosed with increased sensitivity by TRUS compared with rectal examination, but many tumours will still be missed.</li><li>➤ Low-grade tumours</li><li>➤ frequently not seen on MRI</li><li>➤ This problem remains a real one in screening for early prostate cancer; in comparison with breast cancer, with mammography detecting 70–80% of tumours, TRUS plus rectal examination and measurement of PSA will detect only 30–50% of cancers.</li><li>➤ Ref : Bailey 28 th Ed. Pg 1535</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 1535</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 65-year-old male is undergoing a routine health check-up. On a digital rectal exam, a nodular prostate is felt by the clinician. He undergoes further evaluation, where a serum PSA of 4ng/ml is found. TRUS with biopsy shows adenocarcinoma of the prostate, limited to one lobe. Metastatic work up shows no regional nodes or bony metastasis. What would be the recommended management for him?", "options": [{"label": "A", "text": "Robotic radical prostatectomy", "correct": true}, {"label": "B", "text": "Neoadjuvant chemotherapy followed by radical prostatectomy", "correct": false}, {"label": "C", "text": "Active surveillance", "correct": false}, {"label": "D", "text": "Androgen ablation", "correct": false}], "correct_answer": "A. Robotic radical prostatectomy", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Robotic radical prostatectomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Neoadjuvant chemotherapy followed by radical prostatectomy. Neoadjuvant chemotherapy is not standard for low or intermediate-risk , localized prostate cancer prior to prostatectomy.</li><li>• Option B: Neoadjuvant chemotherapy followed by radical prostatectomy.</li><li>• not standard for low or intermediate-risk</li><li>• Option C: Active surveillance. While this is an option for very low-risk or low-risk disease, especially in older men , this patient may be more suitable for definitive treatment given his younger age and potential for long-term survival.</li><li>• Option C: Active surveillance.</li><li>• option for very low-risk or low-risk disease,</li><li>• older men</li><li>• Option D: Androgen ablation therapy. This is used for advanced or metastatic prostate cancer , not for localized disease in a patient who is a good candidate for surgery.</li><li>• Option D: Androgen ablation therapy.</li><li>• advanced or metastatic prostate cancer</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Robotic radical prostatectomy is an appropriate definitive treatment for localized prostate cancer in a patient who is relatively young and has a long life expectancy . This option provides a chance for cure while preserving quality of life.</li><li>➤ Robotic radical prostatectomy</li><li>➤ appropriate definitive treatment for localized prostate cancer</li><li>➤ patient who is relatively young and has a long life expectancy</li><li>➤ Since this is T2 disease in a young patient (&lt;70 years), surgery is the preferred treatment. Low-risk disease: For men in their seventies, conservative treatment is usually the correct approach. Radical surgical treatment might be considered in younger (&lt;70 years) men with this form of the disease and/or with a family history. Intermediate risk disease: In younger (&lt;70 years), fitter men, this may be treated by radical prostatectomy or radical radiotherapy. Active monitoring remains an option, particularly for more elderly patients towards the lower end of the risk spectrum. In elderly patients with outflow obstruction, transurethral resection with or without hormone therapy is indicated.</li><li>➤ Since this is T2 disease in a young patient (&lt;70 years), surgery is the preferred treatment.</li><li>➤ Low-risk disease: For men in their seventies, conservative treatment is usually the correct approach. Radical surgical treatment might be considered in younger (&lt;70 years) men with this form of the disease and/or with a family history.</li><li>➤ Intermediate risk disease: In younger (&lt;70 years), fitter men, this may be treated by radical prostatectomy or radical radiotherapy. Active monitoring remains an option, particularly for more elderly patients towards the lower end of the risk spectrum. In elderly patients with outflow obstruction, transurethral resection with or without hormone therapy is indicated.</li><li>➤ Ref : Bailey 28 th Ed. Pg 1536.</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 1536.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 72-year-old male with advanced prostate cancer is evaluated for therapeutic options. The goal of treatment is to reduce testosterone levels as testosterone stimulates the growth of prostate cancer cells. Which medication is used in the hormonal treatment of advanced prostate cancer to achieve this goal?", "options": [{"label": "A", "text": "Ganirelix", "correct": false}, {"label": "B", "text": "Cetrorelix", "correct": false}, {"label": "C", "text": "Abarelix", "correct": false}, {"label": "D", "text": "Goserelin", "correct": true}], "correct_answer": "D. Goserelin", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Goserelin</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Ganirelix. Ganirelix is a GnRH antagonist used in fertility treatments to prevent premature ovulation , not typically for prostate cancer.</li><li>• Option A: Ganirelix.</li><li>• GnRH antagonist</li><li>• fertility treatments to prevent premature ovulation</li><li>• Option B: Cetrorelix. Like ganirelix, cetrorelix is a GnRH antagonist used in assisted reproduction.</li><li>• Option B: Cetrorelix.</li><li>• cetrorelix is a GnRH antagonist</li><li>• Option C: Abarelix. Abarelix is a GnRH antagonist used in prostate cancer treatment to reduce testosterone levels but is less commonly used than agonists due to the potential for an immediate tumor flare from an antagonist.</li><li>• Option C: Abarelix.</li><li>• GnRH antagonist used in prostate cancer treatment to reduce testosterone levels but is less commonly used</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Goserelin , a GnRH agonist , is commonly used in the treatment of advanced prostate cancer to reduce testosterone production , thus inhibiting the growth of prostate cancer cells . GnRH agonists are preferred over GnRH antagonists for their consistent effect on testosterone suppression after an initial flare .</li><li>➤ Goserelin</li><li>➤ GnRH agonist</li><li>➤ used in the treatment of advanced prostate cancer</li><li>➤ reduce testosterone production</li><li>➤ inhibiting the growth of prostate cancer cells</li><li>➤ GnRH agonists</li><li>➤ GnRH antagonists for their consistent effect on testosterone suppression after an initial flare</li><li>➤ Presently, the use of GnRH agonists-including leuprolide and goserelin, alone or in combination with anti-androgen (e.g.flutamide, bicalutamide or nilutamide) is the preferred approach for treatment of advanced Ca prostate.” “The treatment of choice for patients with advanced prostate cancer is the elimination of testosterone production by the testes through either surgical or chemical castration. Bilateral orchiectomy or estrogen therapy in the form of diethylstilbestrol was previously used as first-line therapy.</li><li>➤ Presently, the use of GnRH agonists-including leuprolide and goserelin, alone or in combination with anti-androgen (e.g.flutamide, bicalutamide or nilutamide) is the preferred approach for treatment of advanced Ca prostate.”</li><li>➤ “The treatment of choice for patients with advanced prostate cancer is the elimination of testosterone production by the testes through either surgical or chemical castration. Bilateral orchiectomy or estrogen therapy in the form of diethylstilbestrol was previously used as first-line therapy.</li><li>➤ Ref : and Love’s short practice of surgery 28 th edition pg 212</li><li>➤ Ref</li><li>➤ : and Love’s short practice of surgery 28 th edition pg 212</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 70-year-old man with prostate cancer was given radiotherapy. The recurrence of the cancer is monitored biochemically by?", "options": [{"label": "A", "text": "Androgens only", "correct": false}, {"label": "B", "text": "Prostate specific antigen and carcinoembryonic antigen", "correct": false}, {"label": "C", "text": "Prostate specific antigen only", "correct": true}, {"label": "D", "text": "ALP and CEA", "correct": false}], "correct_answer": "C. Prostate specific antigen only", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Prostate specific antigen only</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Androgens only. While androgen levels are related to prostate cancer growth , they are not used to monitor for cancer recurrence.</li><li>• Option A: Androgens only.</li><li>• androgen levels are related to prostate cancer growth</li><li>• Option B: PSA and CEA. Carcinoembryonic antigen (CEA) is not typically used to monitor prostate cancer recurrence; it is more commonly associated with colorectal and other cancers.</li><li>• Option B: PSA and CEA.</li><li>• not typically used to monitor prostate cancer recurrence;</li><li>• Option D: ALP and CEA. Alkaline phosphatase (ALP) may be used to monitor for bone metastasis and CEA is not typically used for prostate cancer monitoring.</li><li>• Option D: ALP and CEA.</li><li>• used to monitor for bone metastasis</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Prostate-specific antigen (PSA) is the primary biomarker used for the biochemical monitoring of prostate cancer recurrence following therapy . Biochemical failure after radiotherapy is defined as a rise in PSA by 2 ng/mL higher than the lowest PSA achieved after treatment (Phoenix definition).</li><li>➤ Prostate-specific antigen</li><li>➤ primary biomarker</li><li>➤ biochemical monitoring of prostate cancer recurrence following therapy</li><li>➤ Biochemical failure</li><li>➤ radiotherapy is defined as a rise in PSA by 2 ng/mL higher than the lowest PSA</li><li>➤ Cancer control (In CA Prostate) after radiotherapy has been defined by various criterias including :</li><li>➤ Cancer control (In CA Prostate) after radiotherapy has been defined by various criterias including</li><li>➤ A decline in PSA to less than 0.5 or 1 ng /ml Non rising PSA values Negative biopsy of the prostate 2 years after completion of the treatment</li><li>➤ A decline in PSA to less than 0.5 or 1 ng /ml</li><li>➤ Non rising PSA values</li><li>➤ Negative biopsy of the prostate 2 years after completion of the treatment</li><li>➤ The current standard definition of biochemical failure (the Phoenix definition) is a rise in PSA by &gt; 2 ng/ml higher than the lowest PSA achieved</li><li>➤ Ref : Bailey and Love’s Short Practice of surgery 28th edition 1531-1532</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of surgery 28th edition 1531-1532</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Enuresis, or bedwetting, describes urinary incontinence during sleep, in the absence of congenital or acquired neurological disorders, in any child over the age of?", "options": [{"label": "A", "text": "1 year", "correct": false}, {"label": "B", "text": "2 years", "correct": false}, {"label": "C", "text": "4 years", "correct": false}, {"label": "D", "text": "5 years", "correct": true}], "correct_answer": "D. 5 years", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) 5 years</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Enuresis , or bedwetting , describes urinary incontinence during sleep in any child over the age of 5 years , in the absence of congenital or acquired neurological disorders . Monosymptomatic enuresis (MSE) is defined as enuresis without any other urinary symptoms. Primary MSE describes those who have never achieved night-time continence , whereas secondary MSE refers to those who develop enuresis after a dry period of at least 6 months . Enuresis with any daytime LUTS is defined as non-monosymptomatic enuresis (NMSE).</li><li>• Enuresis , or bedwetting , describes urinary incontinence during sleep in any child over the age of 5 years , in the absence of congenital or acquired neurological disorders .</li><li>• Enuresis</li><li>• bedwetting</li><li>• urinary incontinence during sleep in any child over the age of 5 years</li><li>• absence of congenital or acquired neurological disorders</li><li>• Monosymptomatic enuresis (MSE) is defined as enuresis without any other urinary symptoms.</li><li>• Monosymptomatic enuresis</li><li>• Primary MSE describes those who have never achieved night-time continence , whereas secondary MSE refers to those who develop enuresis after a dry period of at least 6 months .</li><li>• Primary MSE</li><li>• have never achieved night-time continence</li><li>• secondary MSE refers to those who develop enuresis</li><li>• dry period of at least 6 months</li><li>• Enuresis with any daytime LUTS is defined as non-monosymptomatic enuresis (NMSE).</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Enuresis is defined as nighttime urinary incontinence in children over the age of 5 years in the absence of any neurological disorders . At this age, if bedwetting persists, it may warrant further investigation and management.</li><li>➤ Enuresis</li><li>➤ nighttime urinary incontinence in children over the age of 5 years</li><li>➤ absence of any neurological disorders</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1492-1495</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1492-1495</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 52-year-old woman presents with complaints of urinary leakage when she coughs or exercises. She is otherwise healthy and does not report any urgency or difficulty reaching the toilet in time. Which type of urinary incontinence is most consistent with her symptoms?", "options": [{"label": "A", "text": "Stress urinary incontinence", "correct": true}, {"label": "B", "text": "Urgency urinary incontinence", "correct": false}, {"label": "C", "text": "Functional incontinence", "correct": false}, {"label": "D", "text": "Overactive bladder", "correct": false}], "correct_answer": "A. Stress urinary incontinence", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Stress urinary incontinence</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Urgency urinary incontinence. This type of incontinence involves a sudden, intense urge to urinate , followed by involuntary leakage . It is not primarily described by leakage during coughing or physical activities.</li><li>• Option B: Urgency urinary incontinence.</li><li>• incontinence involves a sudden, intense urge to urinate</li><li>• involuntary leakage</li><li>• Option C: Functional incontinence. Functional incontinence occurs when a person recognizes the need to urinate but cannot get to the toilet in time due to physical or cognitive barriers , which is not the case described here.</li><li>• Option C: Functional incontinence.</li><li>• person recognizes the need to urinate</li><li>• cannot get to the toilet in time due to physical or cognitive barriers</li><li>• Option D: Overactive bladder. This is characterized by a sudden urge to urinate that is difficult to control, with or without incontinence, and typically includes symptoms of frequency and nocturia.</li><li>• Option D: Overactive bladder.</li><li>• sudden urge to urinate that is difficult to control,</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Stress urinary incontinence is involuntary leakage on effort or exertion , or on sneezing or coughing, without the presence of an urge to urinate. It is commonly seen in middle-aged women and can be associated with weakened pelvic floor muscles .</li><li>➤ Stress urinary incontinence</li><li>➤ involuntary leakage</li><li>➤ effort or exertion</li><li>➤ sneezing or coughing,</li><li>➤ presence of an urge to urinate.</li><li>➤ commonly seen in middle-aged women</li><li>➤ associated with weakened pelvic floor muscles</li><li>➤ Urgency urinary incontinence (UUI) refers to involuntary leakage accompanied by or immediately preceded by urgency (a sudden compelling desire to pass urine which is difficult to defer). Functional incontinence refers to leakage that results from an inability to reach the toilet because of cognitive, functional or mobility impairments in the presence of an intact LUT system. Overactive bladder (OAB) refers to symptoms of urgency with or without UUI, usually with frequency and nocturia. It can be neurogenic (secondary to a neurological condition) or idiopathic (without identifiable cause).</li><li>➤ Urgency urinary incontinence (UUI) refers to involuntary leakage accompanied by or immediately preceded by urgency (a sudden compelling desire to pass urine which is difficult to defer).</li><li>➤ Functional incontinence refers to leakage that results from an inability to reach the toilet because of cognitive, functional or mobility impairments in the presence of an intact LUT system.</li><li>➤ Overactive bladder (OAB) refers to symptoms of urgency with or without UUI, usually with frequency and nocturia. It can be neurogenic (secondary to a neurological condition) or idiopathic (without identifiable cause).</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1492-1496</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1492-1496</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 55-year-old female with urinary urgency and incontinence undergoes urodynamic testing to evaluate her bladder function. How is the detrusor pressure calculated during urodynamic studies?", "options": [{"label": "A", "text": "By manometry", "correct": false}, {"label": "B", "text": "Intravesical pressure-Intraabdominal pressure", "correct": true}, {"label": "C", "text": "Intrabdominal pressure-Intravesical pressure", "correct": false}, {"label": "D", "text": "Using a transurethral pressure measuring catheter", "correct": false}], "correct_answer": "B. Intravesical pressure-Intraabdominal pressure", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Intravesical pressure-Intraabdominal pressure</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: By manometry. While manometry is a technique used to measure pressure within the urinary system , it is not how detrusor pressure is specifically calculated.</li><li>• Option A: By manometry.</li><li>• technique used to measure pressure within the urinary system</li><li>• Option C: Intraabdominal pressure minus Intravesical pressure. This is incorrect. The formula for calculating detrusor pressure is intravesical pressure minus intra-abdominal pressure , not the other way around.</li><li>• Option C: Intraabdominal pressure minus Intravesical pressure.</li><li>• formula for calculating detrusor pressure is intravesical pressure minus intra-abdominal pressure</li><li>• Option D: Using a transurethral pressure measuring catheter. This option is incorrect. While a catheter is used to measure intravesical pressure , the detrusor pressure is not obtained by this method alone ; it requires the subtraction of intra-abdominal pressure from intravesical pressure.</li><li>• Option D: Using a transurethral pressure measuring catheter.</li><li>• catheter is used to measure intravesical pressure</li><li>• detrusor pressure is not obtained by this method alone</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Detrusor pressure , which reflects the muscle function of the bladder , is derived from measuring the intravesical pressure (inside the bladder) and subtracting the intra-abdominal pressure . This calculation helps in diagnosing the cause of urinary incontinence or other lower urinary tract symptoms.</li><li>➤ Detrusor pressure</li><li>➤ reflects the muscle function of the bladder</li><li>➤ measuring the intravesical pressure</li><li>➤ subtracting the intra-abdominal pressure</li><li>➤ Urodynamic investigation is used to measure the detrusor pressure during filling and voiding. The detrusor pressure cannot be measured directly and so it is derived from subtracting the intra-abdominal pressure from the intravesical pressure Technique . A 6Fr or 8Fr transurethral pressure- measuring catheter is inserted into the bladder to measure the intravesical pressure (pves), and another is inserted into the rectum (or vagina) to measure the intra-abdominal pressure (pabd). The detrusor pressure (pdet) can then be derived by subtracting intra-abdominal pressure from intravesical pressure. Urodynamic studies are used to diagnose patients who have urinary incontinence or other lower urinary tract symptoms.</li><li>➤ Urodynamic investigation is used to measure the detrusor pressure during filling and voiding.</li><li>➤ The detrusor pressure cannot be measured directly and so it is derived from subtracting the intra-abdominal pressure from the intravesical pressure</li><li>➤ Technique . A 6Fr or 8Fr transurethral pressure- measuring catheter is inserted into the bladder to measure the intravesical pressure (pves), and another is inserted into the rectum (or vagina) to measure the intra-abdominal pressure (pabd). The detrusor pressure (pdet) can then be derived by subtracting intra-abdominal pressure from intravesical pressure.</li><li>➤ Technique</li><li>➤ Urodynamic studies are used to diagnose patients who have urinary incontinence or other lower urinary tract symptoms.</li><li>➤ Urodynamic studies are used to diagnose patients who have urinary incontinence or other lower urinary tract symptoms.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1492-1498</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1492-1498</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the grade of vesicoureteral reflux shown in the micturating cystourethrogram below:", "options": [{"label": "A", "text": "Grade 1 VUR", "correct": false}, {"label": "B", "text": "Grade 2 VUR", "correct": false}, {"label": "C", "text": "Grade 4 VUR", "correct": false}, {"label": "D", "text": "Grade 5 VUR", "correct": true}], "correct_answer": "D. Grade 5 VUR", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_QVuO5CT.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2024/03/26/screenshot-2024-03-26-192414.png"], "explanation": "<p><strong>Ans. D) Grade 5 VUR</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Gross dilatation of renal pelvis and calyces are shown with loss of papillary impression with ureteral tortuosity . Thus, this is Grade 5 VUR.</li><li>• Gross dilatation of renal pelvis</li><li>• calyces</li><li>• loss of papillary impression</li><li>• ureteral tortuosity</li><li>• Grade 5 VUR.</li><li>• Grades:</li><li>• Grades:</li><li>• I - Into a nondilated ureter</li><li>• I</li><li>• nondilated ureter</li><li>• II - Into the pelvis and calyces without dilation</li><li>• II</li><li>• pelvis and calyces without dilation</li><li>• III - Mild to moderate dilation of the ureter , renal pelvis, and calyces with min blunting of the fornices</li><li>• III</li><li>• Mild to moderate dilation of the ureter</li><li>• IV - Moderate ureteral tortuosity and dilation of the pelvis and calyces</li><li>• IV</li><li>• Moderate ureteral tortuosity</li><li>• V - Gross dilation of ureter pelvis and calyces ; loss of papillary impressions; and ureteral tortuosity.</li><li>• V</li><li>• Gross dilation of ureter pelvis and calyces</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Severity of vesicoureteral reflux (VUR) using the grading system is based on findings from a micturating cystourethrogram (MCUG). Grade 5 VUR , the most severe form , is characterized by gross dilation of the ureter , renal pelvis , and calyces ; loss of papillary impressions; and marked ureteral tortuosity.</li><li>➤ Severity of vesicoureteral reflux</li><li>➤ grading system is based on findings from a micturating cystourethrogram</li><li>➤ Grade 5 VUR</li><li>➤ severe form</li><li>➤ gross dilation of the ureter</li><li>➤ renal pelvis</li><li>➤ calyces</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 282</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 282</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A retrograde cystogram is performed on a patient with a history of urinary incontinence and difficulty initiating micturition. Identify the condition from the image of the retrograde cystogram shown below:", "options": [{"label": "A", "text": "Radiation cystitis", "correct": false}, {"label": "B", "text": "Drug induced cystitis", "correct": false}, {"label": "C", "text": "Thimble bladder", "correct": false}, {"label": "D", "text": "Neurogenic bladder", "correct": true}], "correct_answer": "D. Neurogenic bladder", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_CHbF5JW.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. D) Neurogenic bladder</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Radiation cystitis Radiation cystitis is inflammation of the bladder that results from radiation treatment , typically for cancers in the pelvic area . It can lead to symptoms such as painful urination, frequent urination, urgency, and hematuria (blood in the urine). On a cystogram, radiation cystitis may show changes in the bladder's contour and capacity, but it does not typically present with the 'Christmas tree' appearance associated with a neurogenic bladder.</li><li>• Option A: Radiation cystitis</li><li>• inflammation of the bladder that results from radiation treatment</li><li>• cancers in the pelvic area</li><li>• Option B: Drug-induced cystitis Certain medications, particularly chemotherapy agents like cyclophosphamide, can cause inflammation of the bladder , known as chemical or drug-induced cystitis . Symptoms may include discomfort during urination, hematuria, and increased frequency and urgency. On imaging, the bladder might appear inflamed and edematous, but without the characteristic features of a neurogenic bladder.</li><li>• Option B: Drug-induced cystitis</li><li>• chemotherapy agents like cyclophosphamide, can cause inflammation of the bladder</li><li>• chemical or drug-induced cystitis</li><li>• Option C: Thimble bladder Thimble bladder refers to a small and contracted bladder, often as a result of chronic bladder outlet obstruction or long-standing infection like TB . In such cases, the bladder capacity is significantly reduced, and the bladder wall may be thickened. This condition is different from a neurogenic bladder and would not produce the 'Christmas tree' appearance on a cystogram.</li><li>• Option C: Thimble bladder</li><li>• small and contracted bladder,</li><li>• chronic bladder outlet obstruction or long-standing infection like TB</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The typical radiographic appearances of various bladder conditions on a cystogram . While a 'Christmas tree' pattern is indicative of a neurogenic bladder , it is essential to distinguish it from other conditions that can affect bladder appearance and function , like radiation cystitis, drug-induced cystitis , and thimble bladder , each of which has distinct characteristics on imaging and in clinical presentation.</li><li>➤ typical radiographic appearances</li><li>➤ various bladder conditions on a cystogram</li><li>➤ 'Christmas tree' pattern</li><li>➤ neurogenic bladder</li><li>➤ essential to distinguish it from other conditions</li><li>➤ affect bladder appearance and function</li><li>➤ radiation cystitis, drug-induced cystitis</li><li>➤ thimble bladder</li><li>➤ The above retrograde cystogram shows the ' Christmas tree’ appearance seen in Neurogenic bladder .</li><li>➤ retrograde cystogram shows the ' Christmas tree’ appearance</li><li>➤ Neurogenic bladder</li><li>➤ Ref : Online resource https://radiopaedia.org/cases/christmas-tree-neurogenic-bladder</li><li>➤ Ref</li><li>➤ : Online resource</li><li>➤ https://radiopaedia.org/cases/christmas-tree-neurogenic-bladder</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 50-year-old woman post abdominal hysterectomy done 1 month ago is asked to do a ‘3 swab test’ Which condition is she likely to be suffering from?", "options": [{"label": "A", "text": "Radiation cystitis", "correct": false}, {"label": "B", "text": "Ca urinary bladder", "correct": false}, {"label": "C", "text": "Vesicovaginal fistulae", "correct": true}, {"label": "D", "text": "Cervicitis", "correct": false}], "correct_answer": "C. Vesicovaginal fistulae", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Vesicovaginal fistulae</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Radiation cystitis. Radiation cystitis is inflammation and damage to the bladder's lining due to radiation therapy , typically used in the treatment of pelvic malignancies such as cervical or bladder cancer . This condition is associated with symptoms like painful urination, blood in the urine, and urinary frequency, but not typically with continuous leakage or a direct connection between the bladder and vagina, as seen in fistulas.</li><li>• Option A: Radiation cystitis.</li><li>• inflammation and damage to the bladder's lining due to radiation therapy</li><li>• used in the treatment of pelvic malignancies</li><li>• cervical or bladder cancer</li><li>• Option B: Carcinoma of the urinary bladder. Carcinoma of the urinary bladder can present with hematuria (blood in the urine), painful urination , and increased urinary frequency or urgency . However, it does not cause a direct fistula between the bladder and vagina. This option would be unlikely in a patient who is being tested with a '3 swab test' for continuous leakage post-hysterectomy.</li><li>• Option B: Carcinoma of the urinary bladder.</li><li>• urinary bladder</li><li>• present with hematuria</li><li>• painful urination</li><li>• increased urinary frequency or urgency</li><li>• Option D: Cervicitis. Cervicitis is inflammation of the cervix , often due to infection . It can present with symptoms such as vaginal discharge, bleeding, and pain, but not urinary incontinence . Since the patient has had a hysterectomy, she would not have a cervix, and this condition would not be consistent with the symptoms or the use of the '3 swab test.'</li><li>• Option D: Cervicitis.</li><li>• inflammation of the cervix</li><li>• due to infection</li><li>• present with symptoms such as vaginal discharge, bleeding, and pain, but not urinary incontinence</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ A '3 swab test' is specifically used to detect the presence of a vesicovaginal fistula , a known complication of such surgeries , which can result in the continuous involuntary passage of urine into the vagina . This test helps to localize the fistula's site and guide subsequent management.</li><li>➤ A '3 swab test'</li><li>➤ used to detect the presence of a vesicovaginal fistula</li><li>➤ known complication of such surgeries</li><li>➤ result in the continuous involuntary passage of urine into the vagina</li><li>➤ Abdominal hysterectomy is three times more likely to result in vesicovaginal fistula than vaginal hysterectomy. VVF is the most common urinary tract fistula, iatrogenic VVF most commonly occurs after hysterectomy, usually thought to be due to an unrecognized bladder injury near the vaginal cuff. ‘Three-swab’ test . This investigation can be performed in cases where fistula is suspected but cannot be identified on the investigations . Three numbered gauze swabs are placed into the vagina, with swab number 1 placed most proximally, swab number 2 in the middle and swab number 3 most distal in the vagina. A blue dye is then instilled into the bladder through a catheter, and the catheter removed. Blue staining of swab 1 or 2 suggests VVF whereas blue staining of swab 3 suggests a urethra- vaginal fistula or stress urinary incontinence. If swab 1 is wet but not stained blue, this suggests the presence of a ureterovaginal fistula.</li><li>➤ Abdominal hysterectomy is three times more likely to result in vesicovaginal fistula than vaginal hysterectomy.</li><li>➤ Abdominal hysterectomy is three times</li><li>➤ result in vesicovaginal fistula</li><li>➤ vaginal hysterectomy.</li><li>➤ VVF is the most common urinary tract fistula, iatrogenic VVF most commonly occurs after hysterectomy, usually thought to be due to an unrecognized bladder injury near the vaginal cuff.</li><li>➤ ‘Three-swab’ test . This investigation can be performed in cases where fistula is suspected but cannot be identified on the investigations . Three numbered gauze swabs are placed into the vagina, with swab number 1 placed most proximally, swab number 2 in the middle and swab number 3 most distal in the vagina. A blue dye is then instilled into the bladder through a catheter, and the catheter removed. Blue staining of swab 1 or 2 suggests VVF whereas blue staining of swab 3 suggests a urethra- vaginal fistula or stress urinary incontinence. If swab 1 is wet but not stained blue, this suggests the presence of a ureterovaginal fistula.</li><li>➤ ‘Three-swab’ test</li><li>➤ performed in cases where fistula is suspected but cannot be identified on the investigations</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1506</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1506</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A recurrent UTI (rUTI) is defined as:", "options": [{"label": "A", "text": "≥2 episodes in 6 months", "correct": false}, {"label": "B", "text": "≥3 episodes in 12 months.", "correct": false}, {"label": "C", "text": "Both", "correct": true}, {"label": "D", "text": "None", "correct": false}], "correct_answer": "C. Both", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Both</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Both A and B are correct. This is the correct answer . Recurrent UTIs are defined as either having at least two infections in 6 months or at least three infections in 12 months . Since the patient had three episodes within a year, her condition fits the full definition of recurrent UTIs.</li><li>• Both A and B are correct.</li><li>• correct answer</li><li>• Recurrent UTIs</li><li>• either having at least two infections in 6 months</li><li>• least three infections in 12 months</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ A recurrent UTI is defined as having at least two episodes within a 6-month period or at least three episodes within a 12-month period .</li><li>➤ recurrent UTI</li><li>➤ having at least two episodes within a 6-month period</li><li>➤ least three episodes within a 12-month period</li><li>➤ An isolated UTI is one in which there has been an interval of at least 6 months between infections . A recurrent UTI (rUTI) is defined as ≥2 episodes in 6 months or ≥3 episodes in 12 months.</li><li>➤ isolated UTI</li><li>➤ one in which there has been an interval of at least 6 months</li><li>➤ between infections</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1510</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1510</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 30-year-old man presents to the clinic with dysuria, urinary frequency, and a sensation of incomplete bladder emptying. He has a history of recreational drug use. A cystoscopy reveals a small, contracted bladder with evidence of chronic inflammation. Which anesthetic agent, also known as a recreational drug, is known to cause such a cystitis if abused?", "options": [{"label": "A", "text": "Thiopentone", "correct": false}, {"label": "B", "text": "Ketamine", "correct": true}, {"label": "C", "text": "Propofol", "correct": false}, {"label": "D", "text": "Etomidate", "correct": false}], "correct_answer": "B. Ketamine", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Ketamine</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Thiopentone. Thiopentone is a barbiturate used for induction of anesthesia. It is not associated with cystitis.</li><li>• Option A: Thiopentone.</li><li>• barbiturate used for induction of anesthesia.</li><li>• Option C: Propofol. Propofol is an anesthetic agent used for the induction and maintenance of anesthesia or sedation. It is not associated with cystitis.</li><li>• Option C: Propofol.</li><li>• anesthetic agent used for the induction and maintenance of anesthesia or sedation.</li><li>• Option D: Etomidate. Etomidate is used for the induction of general anesthesia but is not linked to cystitis.</li><li>• Option D: Etomidate.</li><li>• used for the induction of general anesthesia</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Ketamine cystitis is characterized by severe urinary symptoms and cystoscopic findings of a contracted and inflamed bladder . Cessation of ketamine is the primary treatment, along with supportive measures and potentially major reconstructive surgery in advanced cases.</li><li>➤ Ketamine cystitis is characterized by severe urinary symptoms and cystoscopic findings</li><li>➤ contracted and inflamed bladder</li><li>➤ Ketamine is an N-methyl-d-aspartate (NMDA) antagonist which has become increasingly popular as a recreational ‘street drug’ because of its euphoric and psychedelic effects. As a result of long-term ketamine abuse, up to 30% develop the condition of ketamine cystitis – a chronic inflammatory bladder condition characterized by a small, contracted, inflamed bladder with ureteral stricture and hydronephrosis in advanced cases. Investigation - cystoscopy, bladder biopsy and CT urogram should be performed to exclude other inflammatory or infectious conditions (e.g. TB, schistosomiasis) and to evaluate the effect on the upper urinary tract. Management - Cessation of ketamine use, major reconstructive bladder surgery.</li><li>➤ Ketamine is an N-methyl-d-aspartate (NMDA) antagonist which has become increasingly popular as a recreational ‘street drug’ because of its euphoric and psychedelic effects.</li><li>➤ As a result of long-term ketamine abuse, up to 30% develop the condition of ketamine cystitis – a chronic inflammatory bladder condition characterized by a small, contracted, inflamed bladder with ureteral stricture and hydronephrosis in advanced cases.</li><li>➤ Investigation - cystoscopy, bladder biopsy and CT urogram should be performed to exclude other inflammatory or infectious conditions (e.g. TB, schistosomiasis) and to evaluate the effect on the upper urinary tract.</li><li>➤ Management - Cessation of ketamine use, major reconstructive bladder surgery.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1514</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1514</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 67 years old male presented with fever, chills and dysuria requiring hospitalization for 5 days. P/R examination revealed tenderness over prostate. PSA level was 7.4. What is the next best step in this patient?", "options": [{"label": "A", "text": "Repeat PSA", "correct": false}, {"label": "B", "text": "TURP", "correct": false}, {"label": "C", "text": "TRUS guided biopsy", "correct": false}, {"label": "D", "text": "Antibiotics and admit", "correct": true}], "correct_answer": "D. Antibiotics and admit", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Antibiotics and admit</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Repeat PSA. While repeating the PSA may be considered later on, it is not the next best step in the acute management of a patient with suspected acute bacterial prostatitis.</li><li>• Option A: Repeat PSA.</li><li>• not the next best step in the acute management</li><li>• Option B: TURP. This is a surgical procedure for benign prostatic hyperplasia and is not indicated in the acute management of bacterial prostatitis.</li><li>• Option B: TURP.</li><li>• surgical procedure for benign prostatic hyperplasia</li><li>• Option C: TRUS guided biopsy. This is indicated in the evaluation of prostate cancer , not in the acute setting of bacterial prostatitis , especially when there are signs of infection. Additionally, manipulation of the prostate may exacerbate the infection.</li><li>• Option C: TRUS guided biopsy.</li><li>• evaluation of prostate cancer</li><li>• not in the acute setting of bacterial prostatitis</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Acute bacterial prostatitis is a medical emergency requiring prompt initiation of antibiotic therapy and hospitalization for supportive care . Catheterization and prostatic massage are contraindicated due to the risk of bacteremia and sepsis . Elevated PSA levels can be secondary to inflammation and infection and are not immediately indicative of prostate cancer.</li><li>➤ Acute bacterial prostatitis</li><li>➤ medical emergency requiring prompt initiation of antibiotic therapy</li><li>➤ hospitalization for supportive care</li><li>➤ Catheterization</li><li>➤ prostatic massage</li><li>➤ contraindicated due to the risk of bacteremia and sepsis</li><li>➤ Acute Bacterial Prostatitis</li><li>➤ Acute Bacterial Prostatitis</li><li>➤ Acute inflammation of prostate associated with UTI Caused by ascending urethral infection or reflux of infected urine into prostatic ducts MC organism: E. coli.</li><li>➤ Acute inflammation of prostate associated with UTI</li><li>➤ Caused by ascending urethral infection or reflux of infected urine into prostatic ducts</li><li>➤ MC organism: E. coli.</li><li>➤ Clinical Features:</li><li>➤ Clinical Features:</li><li>➤ Patients present with sudden onset high grade fever with chills and rigors, severe irritative symptoms and enlarged, tender and boggy prostate, Perineal heaviness, rectal irritation and pain on defecation. Per rectal examination reveals a tender prostate; one lobe may be swollen more than the other, and the seminal vesicles may be involved Catheterization and prostatic massage is contraindicated</li><li>➤ Patients present with sudden onset high grade fever with chills and rigors, severe irritative symptoms and enlarged, tender and boggy prostate, Perineal heaviness, rectal irritation and pain on defecation.</li><li>➤ Per rectal examination reveals a tender prostate; one lobe may be swollen more than the other, and the seminal vesicles may be involved</li><li>➤ Catheterization and prostatic massage is contraindicated</li><li>➤ Treatment:</li><li>➤ Treatment:</li><li>➤ MC used antibiotics are: TMP-SMX and Ciprofloxacin (Both are having better concentration in prostatic tissue) Around 4-6 weeks of antibiotic therapy is used to avert chronic bacterial prostatitis.</li><li>➤ MC used antibiotics are: TMP-SMX and Ciprofloxacin (Both are having better concentration in prostatic tissue)</li><li>➤ Around 4-6 weeks of antibiotic therapy is used to avert chronic bacterial prostatitis.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28 th edition pg 1537</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28 th edition pg 1537</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 35-year-old male has undergone high inguinal orchidectomy for a testicular seminoma. Post-operative contrast-enhanced CT (CECT) of the abdomen shows the presence of a few para-aortic lymph nodes, but tumor markers are within normal limits. What is the most appropriate next step in the management of this patient?", "options": [{"label": "A", "text": "Radiotherapy to abdomen", "correct": false}, {"label": "B", "text": "Single cycle chemotherapy", "correct": false}, {"label": "C", "text": "BEP chemotherapy regimen", "correct": true}, {"label": "D", "text": "Retroperitoneal lymph node dissection (RPLND)", "correct": false}], "correct_answer": "C. BEP chemotherapy regimen", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) BEP chemotherapy regimen</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Radiotherapy to the abdomen. This was historically used for early-stage II seminoma, but concerns over long-term risks such as cardiovascular complications and secondary malignancies have shifted the preference towards chemotherapy.</li><li>• Option A: Radiotherapy to the abdomen.</li><li>• historically used for early-stage II seminoma,</li><li>• concerns over long-term risks</li><li>• cardiovascular complications and secondary malignancies</li><li>• Option B: Single cycle of chemotherapy. This is sometimes used in stage I non-seminoma germ cell tumors (NSGCTs) or seminoma but would not be adequate for a stage II seminoma.</li><li>• Option B: Single cycle of chemotherapy.</li><li>• used in stage I non-seminoma germ cell tumors</li><li>• seminoma</li><li>• Option D: Retroperitoneal lymph node dissection (RPLND). This surgical approach may be appropriate for certain NSGCTs, especially postpubertal teratoma without elevated tumor markers , but it is not the first line of treatment for stage II seminoma.</li><li>• Option D: Retroperitoneal lymph node dissection (RPLND).</li><li>• appropriate for certain NSGCTs,</li><li>• postpubertal teratoma without elevated tumor markers</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ To identify that the management of stage II seminoma , characterized by the presence of para-aortic lymph nodes with normal tumor markers following orchiectomy , is with a BEP chemotherapy regimen.</li><li>➤ management of stage II seminoma</li><li>➤ presence of para-aortic lymph nodes</li><li>➤ normal tumor markers following orchiectomy</li><li>➤ BEP chemotherapy regimen.</li><li>➤ Stage I : Seminoma- Radiotherapy/Single cycle chemotherapy</li><li>➤ Stage I</li><li>➤ NSGCT - Adjuvant chemotherapy. One cycle of bleomycin–etoposide– cisplatin (BEP) is now the recommended strategy.</li><li>➤ NSGCT</li><li>➤ Stage II and Stage III : Seminoma/NSGCT- Treatment for metastatic testicular cancer is chemotherapy. Previously, radiotherapy was often used for early-stage II seminoma but the cardiovascular and second malignancy risks have led to chemotherapy (three cycles of BEP or four cycles of etoposide and cisplatin [EP]) being the preferred alternative. Both are similarly effective, with a trend towards greater efficacy for chemotherapy in stage IIB seminoma.</li><li>➤ Stage II and Stage III</li><li>➤ The initial treatment is chemotherapy (BEP) in all advanced cases of NSGCT except postpubertal teratoma without elevated tumour markers , which can be managed by RPLND surgery.</li><li>➤ initial treatment is chemotherapy</li><li>➤ advanced cases of NSGCT except postpubertal teratoma</li><li>➤ without elevated tumour markers</li><li>➤ Ref : Bailey 28 th Ed. Pg 1572</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 1572</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the mismatch prostatectomies:", "options": [{"label": "A", "text": "Young’s- Transperineal", "correct": false}, {"label": "B", "text": "Millon’s- Retropubic", "correct": false}, {"label": "C", "text": "Freyer’s- Perivesical", "correct": true}, {"label": "D", "text": "Holmium laser- Cystoscopy", "correct": false}], "correct_answer": "C. Freyer’s- Perivesical", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Freyer’s- Perivesical</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Young’s prostatectomy - Transperineal. This is correct . Young's prostatectomy is performed via a transperineal approach.</li><li>• Option A: Young’s prostatectomy - Transperineal.</li><li>• correct</li><li>• Option B: Millin’s prostatectomy - Retropubic. This is correct. Millin's technique is a retropubic approach to prostatectomy.</li><li>• Option B: Millin’s prostatectomy - Retropubic.</li><li>• correct.</li><li>• Option D: Holmium laser prostatectomy - Cystoscopy. This is correct. Holmium laser prostatectomy is an endoscopic procedure performed through cystoscopy.</li><li>• Option D: Holmium laser prostatectomy - Cystoscopy.</li><li>• correct.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Types of open prostatectomies for BPH:</li><li>➤ Types of open prostatectomies for BPH:</li><li>➤ Young’s- Trans-perineal Millon’s- Retropubic Freyer’s- Trans-vesical</li><li>➤ Young’s- Trans-perineal</li><li>➤ Millon’s- Retropubic</li><li>➤ Freyer’s- Trans-vesical</li><li>➤ Ref : Bailey 28 th Ed. Pg 1528</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 1528</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 3-year-old boy is brought to the pediatric clinic by his parents due to a scrotal swelling that they have noticed tends to be present at bedtime but is not evident in the morning after the child has been lying down overnight. The swelling is not painful, and there is no history of crying or discomfort associated with the swelling. Based on the history, which of the following is the most likely diagnosis?", "options": [{"label": "A", "text": "Congenital hydrocele", "correct": true}, {"label": "B", "text": "Varicocele", "correct": false}, {"label": "C", "text": "Indirect inguinal hernia", "correct": false}, {"label": "D", "text": "Direct inguinal hernia", "correct": false}], "correct_answer": "A. Congenital hydrocele", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Congenital hydrocele</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Varicocele. This condition is characterized by a 'bag of worms' appearance due to dilated veins of the pampiniform plexus and would not typically resolve with lying down.</li><li>• Option B: Varicocele.</li><li>• characterized by a 'bag of worms' appearance</li><li>• dilated veins of the pampiniform plexus</li><li>• Option C: Indirect inguinal hernia. While a hernia can appear in the scrotum, it typically reduces immediately on lying down as the contents rapidly return back to peritoneal cavity.</li><li>• Option C: Indirect inguinal hernia.</li><li>• hernia can appear in the scrotum,</li><li>• reduces immediately on lying down</li><li>• Option D: Direct inguinal hernia is rarely seen in a 3-year-old , and also reduces immediately.</li><li>• Option D: Direct inguinal hernia</li><li>• rarely seen in a 3-year-old</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The clinical presentation of a congenital hydrocele , which can be identified by a non-reducible scrotal swelling that decreases in size or disappears after the child has been recumbent , as the fluid drains into the peritoneal cavity.</li><li>➤ congenital hydrocele</li><li>➤ identified by a non-reducible scrotal swelling</li><li>➤ decreases in size or disappears after the child has been recumbent</li><li>➤ fluid drains into the peritoneal cavity.</li><li>➤ Hydrocele</li><li>➤ Hydrocele</li><li>➤ In congenital hydrocele , the processus vaginalis is patent and connects with the peritoneal cavity . The communication is usually too small to allow herniation of intra-abdominal contents. Pressure on the hydrocele does not always empty it but the hydrocele fluid may drain into the peritoneal cavity when the child is lying down; thus the hydrocele is often intermittent Thus, a scrotal swelling non reducible but disappears when the child wakes up from sleep is most likely a congenital hydrocele.</li><li>➤ In congenital hydrocele , the processus vaginalis is patent and connects with the peritoneal cavity . The communication is usually too small to allow herniation of intra-abdominal contents.</li><li>➤ congenital hydrocele</li><li>➤ processus vaginalis is patent and connects with the peritoneal cavity</li><li>➤ Pressure on the hydrocele does not always empty it but the hydrocele fluid may drain into the peritoneal cavity when the child is lying down; thus the hydrocele is often intermittent</li><li>➤ Thus, a scrotal swelling non reducible but disappears when the child wakes up from sleep is most likely a congenital hydrocele.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28th edition pg 1564</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28th edition pg 1564</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 72-year-old male presents with urinary hesitancy, decreased stream, and a sensation of incomplete bladder emptying. He has been taking anticoagulation for previous stroke. He has been diagnosed with benign prostatic hyperplasia, and his prostate gland is estimated to be significantly enlarged on digital rectal examination. USG prostate shows a gland of size 80-85g. Considering his diagnosis and the size of the prostate, which treatment modality is preferred for this patient?", "options": [{"label": "A", "text": "TUR-P", "correct": false}, {"label": "B", "text": "HOLEP", "correct": true}, {"label": "C", "text": "Intra-urethral stent", "correct": false}, {"label": "D", "text": "Cryo-ablation", "correct": false}], "correct_answer": "B. HOLEP", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) HOLEP</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: TURP. While TURP is the gold standard treatment for BPH , it may not be the most suitable option for very large prostate glands due to the risk of increased operative time and complications.</li><li>• Option A: TURP.</li><li>• TURP is the gold standard treatment for BPH</li><li>• Option C: Intra-urethral stent. This is generally used as a temporary measure or for patients who are not candidates for surgery.</li><li>• Option C: Intra-urethral stent.</li><li>• used as a temporary measure</li><li>• Option D: Cryoablation. This treatment modality is not the first line for benign prostatic hyperplasia and is more commonly used for prostate cancer.</li><li>• Option D: Cryoablation.</li><li>• not the first line for benign prostatic hyperplasia</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ HOLEP is the preferred treatment modality for patients with very large prostate glands due to its efficacy in removing a significant amount of prostate tissue with a low risk of complications.</li><li>➤ HOLEP</li><li>➤ preferred treatment modality for patients with very large prostate glands</li><li>➤ efficacy in removing a significant amount of prostate tissue</li><li>➤ low risk of complications.</li><li>➤ Interventional measures include transurethral resection of the prostate (TURP), which remains the gold standard; Consider HOLEP (holmium laser enucleation of the prostate), open/ robotic simple prostatectomy for large glands. New minimally invasive treatment options that are available to patients include prostate artery embolisation (PAE), water vapour prostate treatment, prostatic urethral lift (Urolift) and water jet treatment (Aquablation).</li><li>➤ Interventional measures include transurethral resection of the prostate (TURP), which remains the gold standard;</li><li>➤ Consider HOLEP (holmium laser enucleation of the prostate), open/ robotic simple prostatectomy for large glands.</li><li>➤ New minimally invasive treatment options that are available to patients include prostate artery embolisation (PAE), water vapour prostate treatment, prostatic urethral lift (Urolift) and water jet treatment (Aquablation).</li><li>➤ Ref : Bailey 28 th . Ed pg. 1527.</li><li>➤ Ref</li><li>➤ : Bailey 28 th . Ed pg. 1527.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 68-year-old man with a history of urinary frequency and a weak urinary stream undergoes a health screening. His digital rectal examination is notable for a hard, nodular prostate. Which of these levels of Se PSA is suggestive of advanced Ca Prostate?", "options": [{"label": "A", "text": "1.5 to 3.5 ng/ml", "correct": false}, {"label": "B", "text": "3.5 to 10 ng/ml", "correct": false}, {"label": "C", "text": "10 to 35 ng/ml", "correct": false}, {"label": "D", "text": "35 to 100 ng/ml", "correct": true}], "correct_answer": "D. 35 to 100 ng/ml", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) 35 to 100 ng/ml</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• The finding of a PSA &gt;10 ng/mL is suggestive of cancer and &gt;35 ng/mL is almost diagnostic of advanced prostate cancer , in the absence of active urinary tract infection . A decrease in PSA to the normal range following hormonal ablation is a good prognostic sign .</li><li>• finding of a PSA &gt;10 ng/mL</li><li>• cancer and &gt;35 ng/mL</li><li>• diagnostic of advanced prostate cancer</li><li>• absence of active urinary tract infection</li><li>• decrease in PSA</li><li>• normal range</li><li>• hormonal ablation is a good prognostic sign</li><li>• Se PSA level is not significantly altered by DRE :</li><li>• Se PSA level is not significantly altered by DRE</li><li>• Can be significantly altered by a UTI After an infective episode, takes 6 weeks to return to baseline values Is artificially lowered, up to two times, in men taking 5α-reductase inhibitors (finasteride, dutasteride)</li><li>• Can be significantly altered by a UTI</li><li>• After an infective episode, takes 6 weeks to return to baseline values</li><li>• Is artificially lowered, up to two times, in men taking 5α-reductase inhibitors (finasteride, dutasteride)</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• PSA level greater than 35 ng/mL is highly suggestive of advanced prostate cancer in the absence of an active urinary tract infection or other causes of PSA elevation . Further investigation, including biopsy, is usually warranted to confirm the diagnosis and stage the disease.</li><li>• PSA level greater than 35 ng/mL</li><li>• highly suggestive of advanced prostate cancer in the absence of an active urinary tract infection</li><li>• causes of PSA elevation</li><li>• Ref : Bailey 28 th Ed. Pg 1535</li><li>• Ref</li><li>• : Bailey 28 th Ed. Pg 1535</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "What is the preferred treatment option for an 85-year-old patient, diagnosed with prostate cancer with Gleason score 6, having 2 x 3 cm nodules in the prostate and the level of PSA is 8 ng/ml?", "options": [{"label": "A", "text": "Brachytherapy", "correct": false}, {"label": "B", "text": "Palliative external beam radiotherapy", "correct": false}, {"label": "C", "text": "Active surveillance", "correct": true}, {"label": "D", "text": "Radical prostatectomy", "correct": false}], "correct_answer": "C. Active surveillance", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Active surveillance</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Brachytherapy. While this is a treatment option for prostate cancer , it may not be the most appropriate choice for an 85-year-old with a low Gleason score and low PSA, due to the risks associated with the procedure.</li><li>• Option A: Brachytherapy.</li><li>• treatment option for prostate cancer</li><li>• Option B: Palliative external beam radiotherapy. This is generally reserved for symptom management in advanced prostate cancer and may not be necessary for a patient with low-risk disease.</li><li>• Option B: Palliative external beam radiotherapy.</li><li>• generally reserved for symptom management</li><li>• advanced prostate cancer</li><li>• Option D: Radical prostatectomy. This is a treatment option for younger patients with a longer life expectancy or those with more aggressive disease . It's not typically recommended for an 85-year-old with low-risk disease due to the high risk of perioperative morbidity and mortality.</li><li>• Option D: Radical prostatectomy.</li><li>• younger patients with a longer life expectancy</li><li>• more aggressive disease</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Active surveillance is a preferred treatment option for older patients with low-risk prostate cancer , which is defined by a low Gleason score and a PSA level under 10 ng/ml. This approach balances the risks and benefits of treatment in a patient population where the risks of intervention may outweigh the benefits.</li><li>➤ Active surveillance</li><li>➤ preferred treatment option</li><li>➤ older patients with low-risk prostate cancer</li><li>➤ low Gleason score and a PSA level under 10 ng/ml.</li><li>➤ approach balances the risks and benefits of treatment</li><li>➤ Surveillance for CaP:</li><li>➤ Surveillance for CaP:</li><li>➤ Age &gt; 70 years T1 disease, low burden Low PSA (&lt;10 ng/ml) Gleason up to 6</li><li>➤ Age &gt; 70 years</li><li>➤ T1 disease, low burden</li><li>➤ Low PSA (&lt;10 ng/ml)</li><li>➤ Gleason up to 6</li><li>➤ Ref : Bailey 28 th Ed. Pg 1536.</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed. Pg 1536.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 72-year-old male with advanced prostate cancer presents with new-onset bone pain. Imaging studies are being considered to evaluate possible metastatic disease. Prostate cancer commonly metastasizes to the bone via hematogenous spread. Most common site of hematogenous metastasis from Ca Prostate is:", "options": [{"label": "A", "text": "Skull", "correct": false}, {"label": "B", "text": "Pelvic bones", "correct": true}, {"label": "C", "text": "Ribs", "correct": false}, {"label": "D", "text": "Head of Femur", "correct": false}], "correct_answer": "B. Pelvic bones", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Pelvic bones</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Pelvic bones. This is the correct answer . Prostate cancer frequently metastasizes to the pelvic bones and the lower lumbar vertebrae.</li><li>• Pelvic bones.</li><li>• correct answer</li><li>• Prostate cancer</li><li>• metastasizes to the pelvic bones</li><li>• lower lumbar vertebrae.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The pelvic bones are the most common site of hematogenous metastasis from prostate cancer.</li><li>➤ pelvic bones are the most common site of hematogenous metastasis from prostate cancer.</li><li>➤ Spread by the bloodstream occurs particularly to bone; indeed, the prostate is the most common site of origin for skeletal metastases, followed in turn by the breast, the kidney, the bronchus and the thyroid gland. The bones involved most frequently by carcinoma of the prostate are the pelvic bones and the lower lumbar vertebrae (via Bateson’s plexus). The femoral head, ribcage and skull are other common sites. These are osteoblastic metastasis.</li><li>➤ Spread by the bloodstream occurs particularly to bone; indeed, the prostate is the most common site of origin for skeletal metastases, followed in turn by the breast, the kidney, the bronchus and the thyroid gland.</li><li>➤ The bones involved most frequently by carcinoma of the prostate are the pelvic bones and the lower lumbar vertebrae (via Bateson’s plexus). The femoral head, ribcage and skull are other common sites. These are osteoblastic metastasis.</li><li>➤ Ref : Bailey 28 th Ed pg 1532.</li><li>➤ Ref</li><li>➤ : Bailey 28 th Ed pg 1532.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 55-year-old male is undergoing evaluation for recurrent urinary tract infections and a history of urinary stones. On cystoscopy, several bladder diverticula are noted. Which of the following statements is incorrect regarding bladder diverticula?", "options": [{"label": "A", "text": "Can be congenital or acquired", "correct": false}, {"label": "B", "text": "Complications include infection, stones, renal obstruction and rarely malignancy", "correct": false}, {"label": "C", "text": "Bladder outlet obstruction should be identified and, if present, treated prior to bladder diverticulectomy", "correct": false}, {"label": "D", "text": "In congenital diverticula the intravesical pressures are often elevated, and the bladder is thick walled with trabeculations and multiple diverticula.", "correct": true}], "correct_answer": "D. In congenital diverticula the intravesical pressures are often elevated, and the bladder is thick walled with trabeculations and multiple diverticula.", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) In congenital diverticula the intravesical pressures are often elevated, and the bladder is thick walled with trabeculations and multiple diverticula.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Can be congenital or acquired. This statement is true . Bladder diverticula can indeed be congenital or acquired.</li><li>• Option A: Can be congenital or acquired.</li><li>• true</li><li>• Option B: Complications include infection, stones, renal obstruction, and rarely malignancy. This statement is true . These are known complications of bladder diverticula.</li><li>• Option B: Complications include infection, stones, renal obstruction, and rarely malignancy.</li><li>• true</li><li>• Option C: Bladder outlet obstruction should be identified and, if present, treated prior to bladder diverticulectomy. This statement is true . It is important to address any underlying bladder outlet obstruction before surgically treating the diverticula to prevent recurrence and other complications.</li><li>• Option C: Bladder outlet obstruction should be identified and, if present, treated prior to bladder diverticulectomy.</li><li>• true</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Congenital bladder diverticula , which usually occur in a bladder with normal wall thickness and without elevated intravesical pressures , unlike acquired diverticula which are associated with bladder outlet obstruction , high intravesical pressures , and trabeculations.</li><li>➤ Congenital bladder diverticula</li><li>➤ bladder with normal wall thickness and without elevated intravesical pressures</li><li>➤ acquired diverticula</li><li>➤ associated with bladder outlet obstruction</li><li>➤ high intravesical pressures</li><li>➤ trabeculations.</li><li>➤ As opposed to acquired diverticula, intravesical pressures in those with congenital diverticula are not elevated and so the bladder is generally thin walled, without trabeculation or multiple diverticula. In adults with acquired diverticula, the intra- vesical pressures are often elevated, and the bladder is thick walled with trabeculations and multiple diverticula. The raised intravesical pressure causes the lining between the inner layer of hypertrophied muscle to protrude, forming multiple saccules. If a saccule is forced through the bladder wall, it becomes a diverticulum.</li><li>➤ As opposed to acquired diverticula, intravesical pressures in those with congenital diverticula are not elevated and so the bladder is generally thin walled, without trabeculation or multiple diverticula.</li><li>➤ In adults with acquired diverticula, the intra- vesical pressures are often elevated, and the bladder is thick walled with trabeculations and multiple diverticula. The raised intravesical pressure causes the lining between the inner layer of hypertrophied muscle to protrude, forming multiple saccules. If a saccule is forced through the bladder wall, it becomes a diverticulum.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1492</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1492</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A gynecologist is preparing for a hysterectomy and is reviewing the important anatomical structures to avoid intraoperative injury. Which of the following best describes the position of the ureter with respect to the uterine artery?", "options": [{"label": "A", "text": "Anterior", "correct": false}, {"label": "B", "text": "Posterior", "correct": true}, {"label": "C", "text": "Medial", "correct": false}, {"label": "D", "text": "Lateral", "correct": false}], "correct_answer": "B. Posterior", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Posterior</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The anatomical relationship between the ureter and the uterine artery , commonly summarized by the phrase \"water (ureter) under the bridge (uterine artery).\" The ureter passes posteriorly to the uterine artery , which is an important consideration to avoid ureteral injury during pelvic surgeries, such as hysterectomy.</li><li>➤ anatomical relationship</li><li>➤ ureter and the uterine artery</li><li>➤ summarized by the phrase \"water</li><li>➤ under the bridge</li><li>➤ ureter passes posteriorly to the uterine artery</li><li>➤ Ref : Gray’s anatomy 41 st edition, pg 1251</li><li>➤ Ref</li><li>➤ : Gray’s anatomy 41 st edition, pg 1251</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 55-year-old diabetic male presents to the urologist with the below condition on his penis. Identify the condition from the picture below:", "options": [{"label": "A", "text": "Balanitis with phimosis", "correct": true}, {"label": "B", "text": "Ca penis", "correct": false}, {"label": "C", "text": "Normal penis", "correct": false}, {"label": "D", "text": "Candida phimosis", "correct": false}], "correct_answer": "A. Balanitis with phimosis", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_unIzYSD.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. A) Balanitis with phimosis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Ca Penis will present with a cauliflower like mass</li><li>• Option B: Ca Penis will present with a cauliflower like mass</li><li>• Option D: Candida will present with curdy white patches.</li><li>• Option D: Candida will present with curdy white patches.</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Balanoposthitis is common in patients with diabetes . The high glucose environment in diabetic patients contributes to an increased risk of infections like balanitis and complications like phimosis . These patients must manage their blood sugar effectively and practice good hygiene to prevent these conditions.</li><li>• Balanoposthitis</li><li>• common in patients with diabetes</li><li>• high glucose environment</li><li>• diabetic patients</li><li>• increased risk of infections like balanitis</li><li>• complications like phimosis</li><li>• Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1549</li><li>• Ref</li><li>• : Bailey and Love’s short practice of surgery 28 th edition pg 1549</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 69-year-old male presents to the hospital with increased frequency and urgency and dribbling of urine. He also suffers from Parkinson's disease. His urologist starts him on Oxybutynin to improve his symptoms. What could be the probable diagnosis?", "options": [{"label": "A", "text": "Schistosomiasis", "correct": false}, {"label": "B", "text": "Drug induced cystitis", "correct": false}, {"label": "C", "text": "Thimble bladder", "correct": false}, {"label": "D", "text": "Neurogenic bladder", "correct": true}], "correct_answer": "D. Neurogenic bladder", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Neurogenic bladder</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Schistosomiasis. This parasitic infection can affect the urinary tract but is typically associated with hematuria and is not directly related to Parkinson's disease.</li><li>• Option A: Schistosomiasis.</li><li>• parasitic infection</li><li>• affect the urinary tract</li><li>• associated with hematuria</li><li>• Option B: Drug-induced cystitis. While certain drugs can cause inflammation of the bladder , there is no indication that the patient's symptoms are medication-related, especially considering the known diagnosis of Parkinson's disease.</li><li>• Option B: Drug-induced cystitis.</li><li>• drugs can cause inflammation of the bladder</li><li>• Option C: Thimble bladder. This term is used to describe a contracted bladder , often due to chronic obstruction or infection , but is not related to the neurological symptoms seen in Parkinson's disease.</li><li>• Option C: Thimble bladder.</li><li>• used to describe a contracted bladder</li><li>• chronic obstruction or infection</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Neurogenic bladder is a disorder resulting from a nervous system pathology that disrupts normal control of bladder function . Parkinson's disease can lead to neurogenic bladder , presenting with symptoms of urinary frequency, urgency, dribbling, and impaired bladder sensation . Oxybutynin, an anticholinergic medication, can be used to manage these symptoms by reducing bladder muscle contractions.</li><li>➤ Neurogenic bladder</li><li>➤ disorder resulting from a nervous system pathology</li><li>➤ disrupts normal control of bladder function</li><li>➤ Parkinson's disease</li><li>➤ neurogenic bladder</li><li>➤ urinary frequency, urgency, dribbling, and impaired bladder sensation</li><li>➤ The patient discussed above suffers from a neurogenic bladder \"Neurogenic bladder” - urogenital disorders in persons with poor control on urination due to a brain, spinal cord, or nerve issue. Causes - Diabetes, Parkinson's disease,multiple sclerosis (MS) Symptoms - Urinary frequency and urgency, dribbling urine and loss of feeling that the bladder is full. Medications that treat neurogenic bladder include: Oxybutynin, Botulinum toxin</li><li>➤ The patient discussed above suffers from a neurogenic bladder</li><li>➤ \"Neurogenic bladder” - urogenital disorders in persons with poor control on urination due to a brain, spinal cord, or nerve issue.</li><li>➤ Causes - Diabetes, Parkinson's disease,multiple sclerosis (MS)</li><li>➤ Causes</li><li>➤ Symptoms - Urinary frequency and urgency, dribbling urine and loss of feeling that the bladder is full.</li><li>➤ Symptoms</li><li>➤ Medications that treat neurogenic bladder include: Oxybutynin, Botulinum toxin</li><li>➤ Medications</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1504</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1504</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old woman with a history of ovarian cancer treated with chemotherapy and radiotherapy presents to the emergency department with frank hematuria. An ultrasound of the kidneys, ureters, and bladder (USG KUB) reveals a chronic contracted bladder. What is the most likely diagnosis?", "options": [{"label": "A", "text": "Mets to Bladder", "correct": false}, {"label": "B", "text": "Transitional Cell Ca Bladder", "correct": false}, {"label": "C", "text": "Radiation induced cystitis", "correct": true}, {"label": "D", "text": "Chemotherapy induced cystitis", "correct": false}], "correct_answer": "C. Radiation induced cystitis", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Radiation induced cystitis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A: Metastasis to the bladder. While patients with a history of malignancy can have metastasis to the bladder , this typically presents with more focal lesions rather than a generalized bladder contraction.</li><li>• Option A: Metastasis to the bladder.</li><li>• history of malignancy can have metastasis to the bladder</li><li>• Option B: Transitional cell carcinoma of the bladder. This type of bladder cancer can present with hematuria, but it would not typically cause a contracted bladder on imaging.</li><li>• Option B: Transitional cell carcinoma of the bladder.</li><li>• type of bladder cancer can present with hematuria,</li><li>• Option D: Chemotherapy-induced cystitis. Certain chemotherapy drugs can cause cystitis , but they typically cause acute inflammation rather than chronic bladder contraction.</li><li>• Option D: Chemotherapy-induced cystitis.</li><li>• chemotherapy drugs can cause cystitis</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Radiation-induced cystitis is a late complication of pelvic radiotherapy , characterized by a contracted bladder and presenting with hematuria . Treatment options include symptomatic management, cystoscopic interventions, and potentially more radical surgeries like urinary diversion or cystectomy for severe cases.</li><li>➤ Radiation-induced cystitis</li><li>➤ late complication of pelvic radiotherapy</li><li>➤ contracted bladder</li><li>➤ presenting with hematuria</li><li>➤ Radiation cystitis is a common complication of pelvic radiotherapy with incidence rates ranging from 23% to 80%. Radiation treatment causes endothelial cell damage and perivascular fibrosis, resulting in ischaemia and obliterative endarteritis. Haematuria is a common symptom. The end stage is a small, fibrotic bladder Rx- Cystoscopic management with fulguration or laser to bleeding vessels OR urinary diversion with or without cystectomy can be performed for end-stage cases.</li><li>➤ Radiation cystitis is a common complication of pelvic radiotherapy with incidence rates ranging from 23% to 80%.</li><li>➤ Radiation cystitis</li><li>➤ common complication of pelvic radiotherapy</li><li>➤ incidence rates ranging from 23% to 80%.</li><li>➤ Radiation treatment causes endothelial cell damage and perivascular fibrosis, resulting in ischaemia and obliterative endarteritis.</li><li>➤ Haematuria is a common symptom.</li><li>➤ The end stage is a small, fibrotic bladder</li><li>➤ Rx- Cystoscopic management with fulguration or laser to bleeding vessels OR urinary diversion with or without cystectomy can be performed for end-stage cases.</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28 th edition pg 1514</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28 th edition pg 1514</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the condition seen in a male child with symptoms of recurrent UTI and difficulty in voiding:", "options": [{"label": "A", "text": "Normal", "correct": false}, {"label": "B", "text": "Posterior urethral valve", "correct": true}, {"label": "C", "text": "Urethral stricture", "correct": false}, {"label": "D", "text": "Urethral trauma", "correct": false}], "correct_answer": "B. Posterior urethral valve", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/04/28/picture1_uuoTNXe.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B) Posterior urethral valve</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Normal anatomy. A normal VCUG would not show a dilated posterior urethra , which is indicative of an obstructive process.</li><li>• Option A: Normal anatomy.</li><li>• normal VCUG</li><li>• dilated posterior urethra</li><li>• Option C: Urethral stricture. Urethral stricture could cause difficulty in voiding , but it is less common in children and typically does not present with a dilated posterior urethra on imaging.</li><li>• Option C: Urethral stricture.</li><li>• cause difficulty in voiding</li><li>• it is less common in children</li><li>• Option D: Urethral trauma. While urethral trauma can lead to stricture and voiding difficulties, it does not fit with the presentation of a dilated posterior urethra on VCUG.</li><li>• Option D: Urethral trauma.</li><li>• lead to stricture and voiding difficulties,</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Posterior urethral valves are the most common cause of lower urinary tract obstruction in male infants and can lead to recurrent UTIs and voiding issues . They are obstructive to antegrade flow but can often be bypassed retrogradely by a catheter without difficulty.</li><li>➤ Posterior urethral valves</li><li>➤ most common cause of lower urinary tract obstruction in male infants</li><li>➤ lead to recurrent UTIs and voiding issues</li><li>➤ obstructive to antegrade flow</li><li>➤ bypassed retrogradely by a catheter without difficulty.</li><li>➤ Posterior urethral valves are valves with membranes that have a small posterior slit within them. They typically lie just distal to the verumontanum and cause obstruction to the urethra. They function as flap valves; although they are obstructive to antegrade urinary flow, a urethral catheter can be passed retrogradely without any difficulty. Posterior urethral valves need to be detected and treated as early as possible to minimize the degree of renal failure. Investigations include a voiding cystourethrogram (VCUG), which shows a dilated posterior (prostatic) urethra, Treatment is by endoscopic valve ablation</li><li>➤ Posterior urethral valves are valves with membranes that have a small posterior slit within them.</li><li>➤ They typically lie just distal to the verumontanum and cause obstruction to the urethra.</li><li>➤ They function as flap valves; although they are obstructive to antegrade urinary flow, a urethral catheter can be passed retrogradely without any difficulty.</li><li>➤ Posterior urethral valves need to be detected and treated as early as possible to minimize the degree of renal failure.</li><li>➤ Investigations include a voiding cystourethrogram (VCUG), which shows a dilated posterior (prostatic) urethra,</li><li>➤ Treatment is by endoscopic valve ablation</li><li>➤ Ref : Bailey and Love’s short practice of surgery 28th edition pg 1539</li><li>➤ Ref</li><li>➤ : Bailey and Love’s short practice of surgery 28th edition pg 1539</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}]; if (!Array.isArray(questions) || questions.length === 0) { throw new Error("Questions data is empty or invalid"); } debugLog(`Successfully parsed ${questions.length} questions`); } catch (e) { console.error("Failed to parse questions_json:", e); document.getElementById('error-message').innerHTML = "Error loading quiz data. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('start-test').disabled = true; // Fallback to sample questions for testing questions = [ { text: "What is 2 + 2?", options: [ { label: "A", text: "3", correct: false }, { label: "B", text: "4", correct: true }, { label: "C", text: "5", correct: false }, { label: "D", text: "6", correct: false } ], correct_answer: "B. 4", question_images: [], explanation_images: [], explanation: "<p>2 + 2 = 4</p><p>@dams_new_robot</p>", bot: "@dams_new_robot", audio: "", video: "" } ]; debugLog("Loaded fallback questions"); } // Quiz state let currentQuestion = 0; let answers = new Array(questions.length).fill(null); let markedForReview = new Array(questions.length).fill(false); let timeRemaining = 124 * 60; // Duration in seconds let timerInterval = null; const quizId = `{title.replace(/\s+/g, '_').toLowerCase()}`; // Unique ID for local storage // Load saved progress function loadProgress() { try { debugLog("Loading progress from localStorage"); const saved = localStorage.getItem(`quiz_${quizId}`); if (saved) { const { savedAnswers, savedMarked, savedTime } = JSON.parse(saved); answers = savedAnswers || answers; markedForReview = savedMarked || markedForReview; timeRemaining = savedTime !== undefined ? savedTime : timeRemaining; debugLog("Progress loaded successfully"); } else { debugLog("No saved progress found"); } } catch (e) { console.error("Error loading progress:", e); debugLog("Failed to load progress: " + e.message); } } // Save progress function saveProgress() { try { debugLog("Saving progress to localStorage"); localStorage.setItem(`quiz_${quizId}`, JSON.stringify({ savedAnswers: answers, savedMarked: markedForReview, savedTime: timeRemaining })); debugLog("Progress saved successfully"); } catch (e) { console.error("Error saving progress:", e); debugLog("Failed to save progress: " + e.message); } } // Initialize quiz function initQuiz() { try { debugLog("Initializing quiz"); loadProgress(); const startButton = document.getElementById('start-test'); if (!startButton) { throw new Error("Start test button not found"); } startButton.addEventListener('click', startQuiz); debugLog("Start test button listener attached"); document.getElementById('previous-btn').addEventListener('click', showPreviousQuestion); document.getElementById('next-btn').addEventListener('click', showNextQuestion); document.getElementById('mark-review').addEventListener('click', toggleMarkForReview); document.getElementById('nav-toggle').addEventListener('click', toggleNavPanel); document.getElementById('submit-test').addEventListener('click', showSubmitModal); document.getElementById('continue-test').addEventListener('click', closeExitModal); document.getElementById('exit-test').addEventListener('click', () => { debugLog("Exiting test"); localStorage.removeItem(`quiz_${quizId}`); window.location.reload(); }); document.getElementById('cancel-submit').addEventListener('click', closeSubmitModal); document.getElementById('confirm-submit').addEventListener('click', submitTest); document.getElementById('take-again').addEventListener('click', () => { debugLog("Restarting test"); localStorage.removeItem(`quiz_${quizId}`); window.location.reload(); }); document.getElementById('review-test').addEventListener('click', () => showResults(currentResultQuestion)); document.getElementById('close-nav').addEventListener('click', toggleNavPanel); document.getElementById('theme-toggle').addEventListener('click', toggleTheme); document.getElementById('nav-filter').addEventListener('change', updateNavPanel); document.getElementById('prev-result').addEventListener('click', showPreviousResult); document.getElementById('next-result').addEventListener('click', showNextResult); document.getElementById('results-nav-toggle').addEventListener('click', toggleResultsNavPanel); document.getElementById('close-results-nav').addEventListener('click', toggleResultsNavPanel); document.getElementById('results-nav-filter').addEventListener('change', updateResultsNavPanel); debugLog("Quiz initialized successfully"); } catch (e) { console.error("Failed to initialize quiz:", e); debugLog("Failed to initialize quiz: " + e.message); document.getElementById('error-message').innerHTML = "Error initializing quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('start-test').disabled = true; } } // Start quiz function startQuiz() { try { debugLog("Starting quiz"); document.getElementById('instructions').classList.add('hidden'); document.getElementById('quiz').classList.remove('hidden'); showQuestion(currentQuestion); startTimer(); updateNavPanel(); debugLog("Quiz started successfully"); } catch (e) { console.error("Error starting quiz:", e); debugLog("Failed to start quiz: " + e.message); document.getElementById('error-message').innerHTML = "Error starting quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('quiz').classList.add('hidden'); document.getElementById('instructions').classList.remove('hidden'); } } // Show question function showQuestion(index) { try { debugLog(`Showing question ${index + 1}`); currentQuestion = index; const q = questions[index]; if (!q) { throw new Error(`Question ${index} is undefined`); } document.getElementById('question-number').innerHTML = `Question <span>${index + 1}</span> of ${questions.length}`; document.getElementById('question-text').innerHTML = q.text || "No question text available"; const imagesDiv = document.getElementById('question-images'); imagesDiv.innerHTML = q.question_images && q.question_images.length > 0 ? q.question_images.map(url => `<img src="${url}" alt="Question Image" class="max-w-full h-auto rounded-lg">`).join('') : ''; const optionsDiv = document.getElementById('options'); optionsDiv.innerHTML = q.options && q.options.length > 0 ? q.options.map(opt => ` <button class="option-btn w-full text-left p-3 border rounded-lg ${answers[index] === opt.label ? 'selected' : ''}" onclick="selectOption(${index}, '${opt.label}')" aria-label="Option ${opt.label}: ${opt.text}"> ${opt.label}. ${opt.text} </button> `).join('') : '<p class="text-red-500">No options available</p>'; document.getElementById('previous-btn').disabled = index === 0; document.getElementById('next-btn').disabled = index === questions.length - 1; document.getElementById('mark-review').classList.toggle('marked', markedForReview[index]); updateProgressBar(); saveProgress(); window.scrollTo({ top: 0, behavior: 'smooth' }); debugLog(`Question ${index + 1} displayed successfully`); } catch (e) { console.error("Error displaying question:", e); debugLog("Failed to display question: " + e.message); } } // Select option function selectOption(index, label) { try { debugLog(`Selecting option ${label} for question ${index + 1}`); answers[index] = label; const optionsDiv = document.getElementById('options'); const optionButtons = optionsDiv.querySelectorAll('.option-btn'); optionButtons.forEach(btn => { const btnLabel = btn.textContent.trim().split('.')[0]; btn.classList.toggle('selected', btnLabel === label); }); updateNavPanel(); saveProgress(); debugLog(`Option ${label} selected for question ${index + 1}`); } catch (e) { console.error("Error selecting option:", e); debugLog("Failed to select option: " + e.message); } } // Toggle mark for review function toggleMarkForReview() { try { debugLog(`Toggling mark for review on question ${currentQuestion + 1}`); markedForReview[currentQuestion] = !markedForReview[currentQuestion]; document.getElementById('mark-review').classList.toggle('marked', markedForReview[currentQuestion]); updateNavPanel(); saveProgress(); debugLog(`Mark for review toggled for question ${currentQuestion + 1}`); } catch (e) { console.error("Error marking for review:", e); debugLog("Failed to mark for review: " + e.message); } } // Navigate to previous question function showPreviousQuestion() { try { debugLog(`Navigating to previous question from ${currentQuestion + 1}`); if (currentQuestion > 0) { currentQuestion--; showQuestion(currentQuestion); } } catch (e) { console.error("Error navigating to previous question:", e); debugLog("Failed to navigate to previous question: " + e.message); } } // Navigate to next question function showNextQuestion() { try { debugLog(`Navigating to next question from ${currentQuestion + 1}`); if (currentQuestion < questions.length - 1) { currentQuestion++; showQuestion(currentQuestion); } } catch (e) { console.error("Error navigating to next question:", e); debugLog("Failed to navigate to next question: " + e.message); } } // Handle question navigation click function handleQuestionNavClick(index) { try { debugLog(`Navigating to question ${index + 1} via nav panel`); showQuestion(index); toggleNavPanel(); } catch (e) { console.error("Error handling navigation click:", e); debugLog("Failed to navigate via nav panel: " + e.message); } } // Start timer function startTimer() { try { debugLog("Starting timer"); timerInterval = setInterval(() => { if (timeRemaining <= 0) { debugLog("Timer expired, submitting test"); clearInterval(timerInterval); submitTest(); } else { timeRemaining--; const minutes = Math.floor(timeRemaining / 60); const seconds = timeRemaining % 60; document.getElementById('timer').innerHTML = `Time Remaining: <span>${minutes.toString().padStart(2, '0')}:${seconds.toString().padStart(2, '0')}</span>`; saveProgress(); } }, 1000); debugLog("Timer started successfully"); } catch (e) { console.error("Error starting timer:", e); debugLog("Failed to start timer: " + e.message); } } // Update progress bar function updateProgressBar() { try { debugLog("Updating progress bar"); const progress = ((currentQuestion + 1) / questions.length) * 100; document.getElementById('progress-bar').style.width = `${progress}%`; debugLog("Progress bar updated"); } catch (e) { console.error("Error updating progress bar:", e); debugLog("Failed to update progress bar: " + e.message); } } // Update quiz navigation panel function updateNavPanel() { try { debugLog("Updating quiz navigation panel"); const filter = document.getElementById('nav-filter').value; const navGrid = document.getElementById('nav-grid'); navGrid.innerHTML = questions.map((_, i) => { if (filter === 'answered' && !answers[i]) return ''; if (filter === 'unanswered' && answers[i]) return ''; if (filter === 'marked' && !markedForReview[i]) return ''; return ` <button class="question-nav-btn ${answers[i] ? 'answered' : 'unanswered'} ${markedForReview[i] ? 'marked-nav' : ''}" onclick="handleQuestionNavClick(${i})" aria-label="Go to Question ${i + 1}"> ${i + 1} </button> `; }).join(''); debugLog("Quiz navigation panel updated"); } catch (e) { console.error("Error updating quiz navigation panel:", e); debugLog("Failed to update quiz navigation panel: " + e.message); } } // Update results navigation panel function updateResultsNavPanel() { try { debugLog("Updating results navigation panel"); const filter = document.getElementById('results-nav-filter').value; const navGrid = document.getElementById('results-nav-grid'); navGrid.innerHTML = questions.map((_, i) => { if (filter === 'answered' && !answers[i]) return ''; if (filter === 'unanswered' && answers[i]) return ''; if (filter === 'marked' && !markedForReview[i]) return ''; return ` <button class="result-nav-btn-grid ${answers[i] ? 'answered' : 'unanswered'} ${markedForReview[i] ? 'marked-nav' : ''}" onclick="handleResultNavClick(${i})" aria-label="Go to Result for Question ${i + 1}"> ${i + 1} </button> `; }).join(''); debugLog("Results navigation panel updated"); } catch (e) { console.error("Error updating results navigation panel:", e); debugLog("Failed to update results navigation panel: " + e.message); } } // Toggle quiz navigation panel function toggleNavPanel() { try { debugLog("Toggling quiz navigation panel"); const navPanel = document.getElementById('nav-panel'); navPanel.classList.toggle('hidden'); debugLog("Quiz navigation panel toggled"); } catch (e) { console.error("Error toggling quiz navigation panel:", e); debugLog("Failed to toggle quiz navigation panel: " + e.message); } } // Toggle results navigation panel function toggleResultsNavPanel() { try { debugLog("Toggling results navigation panel"); const resultsNavPanel = document.getElementById('results-nav-panel'); resultsNavPanel.classList.toggle('hidden'); if (!resultsNavPanel.classList.contains('hidden')) { updateResultsNavPanel(); } debugLog("Results navigation panel toggled"); } catch (e) { console.error("Error toggling results navigation panel:", e); debugLog("Failed to toggle results navigation panel: " + e.message); } } // Handle result navigation click function handleResultNavClick(index) { try { debugLog(`Navigating to result for question ${index + 1} via nav panel`); showResults(index); toggleResultsNavPanel(); } catch (e) { console.error("Error handling result navigation click:", e); debugLog("Failed to navigate to result: " + e.message); } } // Show submit modal function showSubmitModal() { try { debugLog("Showing submit modal"); const attempted = answers.filter(a => a !== null).length; document.getElementById('attempted-count').textContent = attempted; document.getElementById('unattempted-count').textContent = questions.length - attempted; document.getElementById('submit-modal').classList.remove('hidden'); debugLog("Submit modal displayed"); } catch (e) { console.error("Error showing submit modal:", e); debugLog("Failed to show submit modal: " + e.message); } } // Close submit modal function closeSubmitModal() { try { debugLog("Closing submit modal"); document.getElementById('submit-modal').classList.add('hidden'); debugLog("Submit modal closed"); } catch (e) { console.error("Error closing submit modal:", e); debugLog("Failed to close submit modal: " + e.message); } } // Close exit modal function closeExitModal() { try { debugLog("Closing exit modal"); document.getElementById('exit-modal').classList.add('hidden'); debugLog("Exit modal closed"); } catch (e) { console.error("Error closing exit modal:", e); debugLog("Failed to close exit modal: " + e.message); } } // Submit test function submitTest() { try { debugLog("Submitting test"); clearInterval(timerInterval); document.getElementById('quiz').classList.add('hidden'); document.getElementById('submit-modal').classList.add('hidden'); document.getElementById('results').classList.remove('hidden'); showResults(0); // Start with first question // Trigger confetti animation confetti({ particleCount: 100, spread: 70, origin: { y: 0.6 } }); localStorage.removeItem(`quiz_${quizId}`); debugLog("Test submitted successfully"); } catch (e) { console.error("Error submitting test:", e); debugLog("Failed to submit test: " + e.message); } } // Show result for a single question function showResults(index) { try { debugLog(`Showing result for question ${index + 1}`); currentResultQuestion = index; let correct = 0, wrong = 0, unanswered = 0, marked = 0; answers.forEach((answer, i) => { const isCorrect = answer && questions[i].options.find(opt => opt.label === answer)?.correct; if (answer === null) unanswered++; else if (isCorrect) correct++; else wrong++; if (markedForReview[i]) marked++; }); const q = questions[index]; if (!q) { throw new Error(`Question ${index} is undefined`); } const userAnswer = answers[index]; const isCorrect = userAnswer && q.options.find(opt => opt.label === userAnswer)?.correct; const resultsContent = document.getElementById('results-content'); resultsContent.innerHTML = ` <div class="border p-4 rounded-lg ${isCorrect ? 'bg-green-50' : userAnswer ? 'bg-red-50' : 'bg-gray-50'}"> <p class="font-semibold">Question ${index + 1}: ${q.text || 'No question text'}</p> ${q.question_images && q.question_images.length > 0 ? q.question_images.map(url => `<img src="${url}" alt="Question Image" class="max-w-full h-auto rounded-lg my-2">`).join('') : ''} <p><strong>Your Answer:</strong> ${userAnswer ? `${userAnswer}. ${q.options.find(opt => opt.label === userAnswer)?.text || 'Invalid option'}` : 'Unanswered'}</p> <p><strong>Correct Answer:</strong> ${q.correct_answer || 'Unknown'}</p> <div class="mt-2">${q.explanation || 'No explanation available'}</div> ${q.explanation_images && q.explanation_images.length > 0 ? q.explanation_images.map(url => `<img src="${url}" alt="Explanation Image" class="max-w-full h-auto rounded-lg my-2">`).join('') : ''} ${q.video ? ` <button class="play-video bg-blue-500 text-white px-4 py-2 rounded-lg mt-2" onclick="loadVideo(this, '${q.video}', 'video-${index}')" aria-label="Play explanation video for Question ${index + 1}"> Play Video Explanation </button> <div id="video-${index}" class="video-container mt-2"></div> ` : '<p class="text-gray-500 mt-2">No video available</p>'} ${q.audio ? ` <button class="play-audio bg-blue-500 text-white px-4 py-2 rounded-lg mt-2" onclick="loadAudio(this, '${q.audio}', 'audio-${index}')" aria-label="Play audio explanation for Question ${index + 1}"> Play Audio Explanation </button> <div id="audio-${index}" class="audio-container mt-2"></div> ` : ''} </div> `; document.getElementById('correct-count').textContent = correct; document.getElementById('wrong-count').textContent = wrong; document.getElementById('unanswered-count').textContent = unanswered; document.getElementById('marked-count').textContent = marked; document.getElementById('result-question-number').innerHTML = `Question <span>${index + 1}</span> of ${questions.length}`; document.getElementById('prev-result').disabled = index === 0; document.getElementById('next-result').disabled = index === questions.length - 1; updateResultsNavPanel(); window.scrollTo({ top: 0, behavior: 'smooth' }); debugLog(`Result for question ${index + 1} displayed successfully`); } catch (e) { console.error("Error displaying result:", e); debugLog("Failed to display result: " + e.message); } } // Navigate to previous result function showPreviousResult() { try { debugLog(`Navigating to previous result from question ${currentResultQuestion + 1}`); if (currentResultQuestion > 0) { showResults(currentResultQuestion - 1); } } catch (e) { console.error("Error navigating to previous result:", e); debugLog("Failed to navigate to previous result: " + e.message); } } // Navigate to next result function showNextResult() { try { debugLog(`Navigating to next result from question ${currentResultQuestion + 1}`); if (currentResultQuestion < questions.length - 1) { showResults(currentResultQuestion + 1); } } catch (e) { console.error("Error navigating to next result:", e); debugLog("Failed to navigate to next result: " + e.message); } } // Lazy-load video function loadVideo(button, videoUrl, containerId) { try { debugLog(`Loading video for ${containerId}: ${videoUrl}`); if (!videoUrl) { const container = document.getElementById(containerId); container.innerHTML = `<p class="text-gray-500">No video available</p>`; button.remove(); debugLog("No video URL provided"); return; } const container = document.getElementById(containerId); container.innerHTML = ` <div class="video-loading"></div> <video controls class="w-full max-w-[600px] rounded-lg" preload="metadata" aria-label="Video explanation"> <source src="${videoUrl}" type="${videoUrl.endsWith('.m3u8') ? 'application/x-mpegURL' : 'video/mp4'}"> Your browser does not support the video tag. </video> `; container.classList.add('active'); button.remove(); // Initialize HLS.js for .m3u8 videos const video = container.querySelector('video'); if (videoUrl.endsWith('.m3u8') && Hls.isSupported()) { const hls = new Hls(); hls.loadSource(videoUrl); hls.attachMedia(video); hls.on(Hls.Events.ERROR, (event, data) => { console.error("HLS.js error:", data); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; debugLog("HLS.js error: " + JSON.stringify(data)); }); } else if (videoUrl.endsWith('.m3u8') && video.canPlayType('application/vnd.apple.mpegurl')) { video.src = videoUrl; } // Handle video load errors video.onerror = () => { console.error("Video load error for URL:", videoUrl); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; debugLog("Video load error for URL: " + videoUrl); }; // Remove loading spinner when video is ready video.onloadedmetadata = () => { container.querySelector('.video-loading').remove(); debugLog("Video loaded successfully"); }; } catch (e) { console.error("Error loading video:", e); debugLog("Failed to load video: " + e.message); const container = document.getElementById(containerId); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; } } // Lazy-load audio function loadAudio(button, audioUrl, containerId) { try { debugLog(`Loading audio for ${containerId}: ${audioUrl}`); if (!audioUrl) { const container = document.getElementById(containerId); container.innerHTML = `<p class="text-gray-500">No audio available</p>`; button.remove(); debugLog("No audio URL provided"); return; } const container = document.getElementById(containerId); container.innerHTML = ` <audio controls class="w-full max-w-[600px]" preload="metadata" aria-label="Audio explanation"> <source src="${audioUrl}" type="audio/mpeg"> Your browser does not support the audio tag. </audio> `; container.classList.add('active'); button.remove(); // Handle audio load errors const audio = container.querySelector('audio'); audio.onerror = () => { console.error("Audio load error for URL:", audioUrl); container.innerHTML = `<p class="text-red-500">Error loading audio. <a href="${audioUrl}" target="_blank" aria-label="Open audio in new tab">Open audio</a></p>`; debugLog("Audio load error for URL: " + audioUrl); }; debugLog("Audio loaded successfully"); } catch (e) { console.error("Error loading audio:", e); debugLog("Failed to load audio: " + e.message); const container = document.getElementById(containerId); container.innerHTML = `<p class="text-red-500">Error loading audio. <a href="${audioUrl}" target="_blank" aria-label="Open audio in new tab">Open audio</a></p>`; } } // Toggle dark mode function toggleTheme() { try { debugLog("Toggling theme"); document.documentElement.classList.toggle('dark'); localStorage.setItem('theme', document.documentElement.classList.contains('dark') ? 'dark' : 'light'); debugLog("Theme toggled successfully"); } catch (e) { console.error("Error toggling theme:", e); debugLog("Failed to toggle theme: " + e.message); } } // Load theme preference function loadTheme() { try { debugLog("Loading theme preference"); const theme = localStorage.getItem('theme'); if (theme === 'dark') { document.documentElement.classList.add('dark'); } debugLog("Theme loaded successfully"); } catch (e) { console.error("Error loading theme:", e); debugLog("Failed to load theme: " + e.message); } } // Initialize on DOM content loaded window.addEventListener('DOMContentLoaded', () => { try { debugLog("DOM content loaded, initializing quiz"); loadTheme(); initQuiz(); } catch (e) { console.error("Error during DOMContentLoaded:", e); debugLog("Failed to initialize on DOMContentLoaded: " + e.message); document.getElementById('error-message').innerHTML = "Error initializing quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); } }); </script> </body> </html>" frameborder="0" width="100%" height="2000px">
<div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <h2 class="text-xl font-semibold mb-4">Instructions</h2> <h4 class="text-gray-800 text-lg font-semibold mt-6 mb-4">Test Features:</h4> <ul class="space-y-3"> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Multiple choice questions with single correct answers </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Timer-based testing for realistic exam conditions </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Mark questions for review functionality </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Comprehensive results and performance analysis </li> <li class="flex items-center gap-3"> <i class="fa-solid fa-circle-check text-green-500"></i> Mobile-optimized interface for learning on-the-go </li> </ul> <div class="mt-6 flex space-x-4 button-group md:flex-row flex-col"> <button class="bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="start-test">Start Test</button> </div> <div class="error-message hidden" id="error-message"></div> </div> </section> <!-- Quiz Section --> <section class="container mx-auto px-4 md:px-6 pt-4 md:pt-6 pb-1 hidden section-transition" id="quiz"> <div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <!-- Progress Bar --> <div class="w-full bg-gray-200 rounded-full h-3 mb-4"> <div class="progress-bar h-3 rounded-full" id="progress-bar" style="width: 0%"></div> </div> <!-- Question Header --> <div class="flex flex-col md:flex-row justify-between items-center mb-4"> <h2 class="text-lg font-semibold" id="question-number">Question <span>1</span> of 4</h2> <p class="text-lg font-semibold mt-2 md:mt-0" id="timer">Time Remaining: <span>00:00</span></p> </div> <!-- Question Content --> <div class="mb-6" id="question-content"> <p class="text-gray-800 mb-4" id="question-text"></p> <div class="flex flex-wrap gap-4 mb-4" id="question-images"></div> <div class="space-y-3" id="options"></div> </div> <!-- Navigation Buttons --> <div class="flex flex-col md:flex-row justify-between items-center gap-2 md:gap-4"> <div class="flex gap-2 w-full md:w-auto"> <button class="bg-[#2c5281] text-white px-4 py-3 w-full md:w-32 h-14 rounded-lg hover:bg-[#2c5281] transition" disabled="" id="previous-btn">Previous</button> <button class="bg-[#2c5281] text-white px-4 py-3 w-full md:w-32 h-14 rounded-lg hover:bg-[#2c5281] transition" id="next-btn">Next</button> </div> <div class="flex items-center gap-2"> <button class="bg-transparent text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-100 transition flex items-center gap-1" id="mark-review"> Review <svg xmlns="http://www.w3.org/2000/svg" class="h-5 w-5" viewBox="0 0 20 20" fill="currentColor"> <path d="M10 2a1 1 0 00-1 1v14l3.293-3.293a1 1 0 011.414 0L17 17V3a1 1 0 00-1-1H10z" /> </svg> </button> <button class="bg-transparent text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-100 transition flex items-center gap-1" id="nav-toggle"> Question 🧭 </button> <button class="bg-green-500 text-white px-6 py-3 w-44 h-14 rounded-lg hover:bg-green-600 transition w-full md:w-auto" id="submit-test">Submit Test</button> </div> </div> </section> <!-- Results Section --> <section class="container mx-auto px-4 md:px-6 pt-4 md:pt-6 pb-1 hidden section-transition" id="results"> <div class="bg-white rounded-lg shadow-md p-4 md:p-6"> <h2 class="text-2xl font-semibold mb-4">Anaesthesia Machine - Results</h2> <div class="grid grid-cols-1 md:grid-cols-2 gap-4 mb-6"> <p><strong>Correct:</strong> <span id="correct-count" class="text-[#000000]">0</span></p> <p><strong>Wrong:</strong> <span id="wrong-count" class="text-[#000000]">0</span></p> <p><strong>Unanswered:</strong> <span id="unanswered-count" class="text-[#000000]-500">0</span></p> <p><strong>Marked for Review:</strong> <span id="marked-count" class="text-[#000000]">0</span></p> </div> <h3 class="text-lg font-semibold mb-4" id="result-question-number">Question <span>1</span> of 4</h3> <div class="space-y-6" id="results-content"></div> <div class="result-nav"> <button aria-label="Previous question result" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" disabled="" id="prev-result">Previous</button> <button aria-label="Toggle results navigation panel" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="results-nav-toggle">Result 🧭</button> <button aria-label="Next question result" class="result-nav-btn bg-[#2c5281] text-white px-6 py-2 rounded-lg hover:bg-[#2c5281] transition" id="next-result">Next</button> </div> <div class="mt-6 flex space-x-4 button-group md:flex-row flex-col"> <button class="bg-green-500 text-white px-6 py-2 rounded-lg hover:bg-green-600 transition" id="take-again">Take Again</button> </div> </div> </section> <!-- Exit Confirmation Modal --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 hidden" id="exit-modal" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white rounded-lg p-6 max-w-sm w-full"> <h2 class="text-xl font-semibold mb-4">Leave Test?</h2> <p class="text-gray-700 mb-4">Your progress will be lost if you leave this page. Are you sure you want to exit?</p> <div class="flex justify-end space-x-4"> <button class="bg-gray-300 text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-400 transition" id="continue-test">No, Continue</button> <button class="bg-red-500 text-white px-4 py-2 rounded-lg hover:bg-red-600 transition" id="exit-test">Yes, Exit</button> </div> </div> </div> <!-- Submit Confirmation Modal --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 hidden" id="submit-modal" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white rounded-lg p-6 max-w-sm w-full"> <h2 class="text-xl font-semibold mb-4">Confirm Submission</h2> <p class="text-gray-700 mb-2">You have attempted <span id="attempted-count">0</span> of 4 questions.</p> <p class="text-gray-700 mb-4"><span id="unattempted-count">0</span> questions are unattempted.</p> <div class="flex justify-end space-x-4"> <button class="bg-gray-300 text-gray-700 px-4 py-2 rounded-lg hover:bg-gray-400 transition" id="cancel-submit">Cancel</button> <button class="text-white px-4 py-2 rounded-lg hover:bg-[#1a365d] transition" style="background-color: #2c5281;" id="confirm-submit">Submit Test</button> </div> </div> </div> <!-- Quiz Navigation Panel --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 z-50 nav-panel hidden overflow-y-auto" id="nav-panel" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white shadow-lg p-4 rounded-lg w-full max-w-2xl max-h-[80vh] overflow-y-auto"> <h2 class="text-lg font-semibold mb-4">Questions Navigation</h2> <div class="mb-4"> <select class="w-full p-2 border rounded-lg text-gray-700" id="nav-filter"> <option value="all">All Questions</option> <option value="answered">Answered</option> <option value="unanswered">Unanswered</option> <option value="marked">Marked for Review</option> </select> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-nav">Close</button> </div> </div> <!-- Results Navigation Panel --> <div class="fixed inset-0 bg-black bg-opacity-50 flex items-start justify-center p-4 z-50 results-nav-panel hidden overflow-y-auto" id="results-nav-panel" style="align-items: flex-start; padding-top: 33vh;"> <div class="bg-white shadow-lg p-4 rounded-lg w-full max-w-2xl max-h-[80vh] overflow-y-auto"> <h2 class="text-lg font-semibold mb-4">Results Navigation</h2> <div class="mb-4"> <select class="w-full p-2 border rounded-lg text-gray-700" id="results-nav-filter"> <option value="all">All Questions</option> <option value="answered">Answered</option> <option value="unanswered">Unanswered</option> <option value="marked">Marked for Review</option> </select> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="results-nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-results-nav">Close</button> </div> </div> <div class="grid grid-cols-5 gap-2 md:gap-3" id="results-nav-grid"></div> <button class="mt-4 bg-gray-500 text-white px-4 py-2 rounded-lg hover:bg-gray-600 transition w-full" id="close-results-nav">Close</button> </div> <!-- JavaScript Logic --> <script> // Enable debug mode for detailed logging const DEBUG_MODE = true; // Log debug messages function debugLog(message) { if (DEBUG_MODE) { console.log(`[DEBUG] ${message}`); } } // Initialize questions with error handling let questions = []; let currentResultQuestion = 0; // State for current question in results try { debugLog("Attempting to parse questions_json"); questions = [{"text": "A patient with long-standing lymphedema post modified radical mastectomy (MRM) 2 years ago presented with acute worsening of the lymphedema and the following finding on examination. What is the most likely diagnosis?", "options": [{"label": "A", "text": "Cellulitis", "correct": false}, {"label": "B", "text": "Stewart Treves syndrome", "correct": true}, {"label": "C", "text": "Breast cancer metastasis", "correct": false}, {"label": "D", "text": "Seroma formation", "correct": false}], "correct_answer": "B. Stewart Treves syndrome", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/14/picture14.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B) Stewart Treves syndrome</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A: Cellulitis. Incorrect . While cellulitis can occur in patients with lymphedema, the acute worsening of lymphedema with the appearance of bluish-red skin and multiple subcutaneous nodules , as described in the scenario, is not characteristic of cellulitis.</li><li>• Option A: Cellulitis. Incorrect</li><li>• cellulitis can occur in patients with lymphedema,</li><li>• acute worsening of lymphedema with the appearance of bluish-red skin</li><li>• multiple subcutaneous nodules</li><li>• Option C: Breast cancer metastasis. Incorrect . While breast cancer metastasis is a possibility , the presentation described is more suggestive of Stewart Treves syndrome , which is a specific complication of lymphedema in breast cancer patients.</li><li>• Option C: Breast cancer metastasis. Incorrect</li><li>• breast cancer metastasis is a possibility</li><li>• Stewart Treves syndrome</li><li>• Option D: Seroma formation is an immediate post operative complication .</li><li>• Option D: Seroma</li><li>• formation</li><li>• immediate post operative complication</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ Stewart Treves syndrome , is a rare complication of long-standing lymphedema in breast cancer patients, characterized by the development of lymphangiosarcoma in the affected limb .</li><li>➤ Stewart Treves syndrome</li><li>➤ rare complication of long-standing lymphedema in breast cancer</li><li>➤ development of lymphangiosarcoma in the affected limb</li><li>➤ Ref : Sabiston Textbook of Surgery 20th Edition Page 1855.</li><li>➤ Ref</li><li>➤ : Sabiston Textbook of Surgery 20th Edition Page 1855.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient present with buttock, thigh and calf claudication bilaterally, since the last few months. He also complains of impotence. What is the diagnosis and the site of obstruction?", "options": [{"label": "A", "text": "Lhermitte syndrome, aortoiliac obstruction", "correct": false}, {"label": "B", "text": "Leriche syndrome, Iliac obstruction", "correct": false}, {"label": "C", "text": "Leriche syndrome, aortoiliac obstruction", "correct": true}, {"label": "D", "text": "Lhermitte syndrome, iliac obstruction", "correct": false}], "correct_answer": "C. Leriche syndrome, aortoiliac obstruction", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/13/screenshot-2023-12-13-112912.jpg"], "explanation": "<p><strong>Ans. C)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Leriche ’ s syndrome is buttock claudication combined with sexual impotence, which is secondary to arterial insufficiency (aortoiliac occlusion). It is most commonly seen due to atherosclerosis.</li><li>• Leriche</li><li>• s syndrome</li><li>• buttock claudication</li><li>• sexual impotence, which is secondary to arterial insufficiency</li><li>• most commonly seen due to atherosclerosis.</li><li>• Lhermitte's phenomenon also referred to as the barber chair phenomenon is the name which describes an electric shock-like sensation that occurs on flexion of the neck , seen in cervical spondylitis , multiple sclerosis etc.</li><li>• Lhermitte's phenomenon</li><li>• barber chair phenomenon</li><li>• electric shock-like sensation that occurs on flexion of the neck</li><li>• cervical spondylitis</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Sites of obstruction and their respective clinical findings-</li><li>➤ Sites of obstruction</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 998-1000</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 998-1000</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient came with dilated tortuous swellings in both legs as shown. What will your investigation of choice to confirm the diagnosis?", "options": [{"label": "A", "text": "CT venography", "correct": false}, {"label": "B", "text": "MR venography", "correct": false}, {"label": "C", "text": "Duplex scan", "correct": true}, {"label": "D", "text": "Digital subtraction imaging", "correct": false}], "correct_answer": "C. Duplex scan", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/13/picture10_ppcoq6U.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Duplex scan</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: CT Venography. CT venography involves the use of computed tomography to visualize the venous system after the injection of contrast material . It is typically used for deep venous thrombosis and other venous disorders.</li><li>• Option A: CT Venography.</li><li>• use of computed tomography to visualize the venous system after the injection of contrast material</li><li>• Option B: MR Venography. MR venography uses magnetic resonance imaging to provide detailed images of the venous system without the use of radiation . Like CT venography, it is more commonly used for complex venous disorders and is not the primary choice for diagnosing varicose veins.</li><li>• Option B: MR Venography.</li><li>• magnetic resonance imaging to provide detailed images of the venous system</li><li>• without the</li><li>• use of radiation</li><li>• Option D: Digital Subtraction Imaging. Digital subtraction angiography (DSA) is an imaging technique used to visualize arteries by subtracting a pre-contrast image from subsequent images taken after contrast injection.</li><li>• Option D: Digital Subtraction Imaging.</li><li>• imaging technique used to visualize arteries by subtracting a pre-contrast image from subsequent images</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Duplex ultrasonography is used as the primary diagnostic tool for varicose veins , because of its ability to assess both venous structure and function without the risks associated with radiation or contrast exposure.</li><li>➤ Duplex ultrasonography</li><li>➤ primary diagnostic tool for varicose veins</li><li>➤ ability to assess both venous structure</li><li>➤ function without the risks associated with radiation or contrast exposure.</li><li>➤ The aim of the duplex scan in a patient with varicose veins is to establish:</li><li>➤ The presence of reflux in the deep and superficial venous system The exact distribution and extent of reflux in the superficial venous system, including affected junctions and perforators The presence of obstruction in the deep venous system The suitability of the incompetent superficial veins for the different treatments available (based upon diameter, extent, tortuosity, saphena varix) The presence of thrombus within the superficial veins An indication of a pelvic source of reflux or obstruction.</li><li>➤ The presence of reflux in the deep and superficial venous system</li><li>➤ The exact distribution and extent of reflux in the superficial venous system, including affected junctions and perforators</li><li>➤ The presence of obstruction in the deep venous system</li><li>➤ The suitability of the incompetent superficial veins for the different treatments available (based upon diameter, extent, tortuosity, saphena varix)</li><li>➤ The presence of thrombus within the superficial veins An indication of a pelvic source of reflux or obstruction.</li><li>➤ An indication of a pelvic source of reflux or obstruction.</li><li>➤ An indication of a pelvic source of reflux or obstruction.</li><li>➤ Pelvic and iliac veins may be investigated using transabdominal or transvaginal duplex. Very occasionally investigations other than duplex are required, and these may be non-invasive, such as magnetic resonance (MR) venography, or invasive, such as contrast venography.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1032</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1032</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient was being examined for suspected Peripheral Arterial Disease. On history, he had complaints of claudication in right calf. On examination, his right sided femoral pulse was present but all pulses distal to that were absent. Left side was normal on examination. What is the most likely site of obstruction?", "options": [{"label": "A", "text": "Femoropopliteal obstruction", "correct": true}, {"label": "B", "text": "Aortoiliac obstruction", "correct": false}, {"label": "C", "text": "Iliac obstruction", "correct": false}, {"label": "D", "text": "Posterior tibial obstruction", "correct": false}], "correct_answer": "A. Femoropopliteal obstruction", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/13/screenshot-2023-12-13-114739.jpg"], "explanation": "<p><strong>Ans. A)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. Aortoiliac obstruction. Incorrect . Aortoiliac obstruction would typically affect pulses more proximally , including the femoral pulse, and lead to bilateral gluteal claudication</li><li>• Option B. Aortoiliac obstruction. Incorrect</li><li>• affect pulses more proximally</li><li>• Option C. Iliac obstruction. Incorrect. Iliac obstruction alone wouldn't explain the absence of pulses distal to the right femoral pulse . It would lead to thigh claudication.</li><li>• Option C. Iliac obstruction.</li><li>• Iliac obstruction</li><li>• wouldn't explain the absence of pulses distal to the right femoral pulse</li><li>• Option D. Posterior tibial obstruction. Incorrect. Posterior tibial obstruction would lead to claudication in the foot .</li><li>• Option D. Posterior tibial obstruction.</li><li>• would lead to claudication in the foot</li><li>• Educational objective</li><li>• Educational objective</li><li>• Sites of obstruction and their respective clinical findings-</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 998-1000</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Page 998-1000</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "With regard to arterial occlusive disease, pick the incorrect statement:", "options": [{"label": "A", "text": "The most common cause of peripheral arterial disease is atherosclerosis.", "correct": false}, {"label": "B", "text": "The most common symptom of chronic lower limb arterial stenosis is intermittent claudication.", "correct": false}, {"label": "C", "text": "Chronic stenosis has a more severe presentation, as compared to acute limb ischemia.", "correct": true}, {"label": "D", "text": "Intermittent claudication mainly occurs due to anaerobic muscle metabolism.", "correct": false}], "correct_answer": "C. Chronic stenosis has a more severe presentation, as compared to acute limb ischemia.", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Chronic stenosis has a more severe presentation, as compared to acute limb ischemia.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. The most common cause of peripheral arterial disease is atherosclerosis . This statement is correct . Atherosclerosis, characterized by the build-up of plaques in arteries, is a leading cause of peripheral arterial disease.</li><li>• Option A.</li><li>• The</li><li>• most common cause of peripheral arterial disease is atherosclerosis</li><li>• correct</li><li>• Option B. The most common symptom of chronic lower limb arterial stenosis is intermittent claudication . This statement is correct . Intermittent claudication, characterized by muscle pain during physical activity, is a common symptom of chronic lower limb arterial stenosis.</li><li>• Option B.</li><li>• The most common symptom of chronic lower limb arterial stenosis is intermittent claudication</li><li>• correct</li><li>• Option D. Intermittent claudication mainly occurs due to anaerobic muscle metabolism. This statement is correct . Intermittent claudication results from inadequate oxygen supply to muscles during physical activity, leading to anaerobic metabolism.</li><li>• Option D.</li><li>• Intermittent claudication mainly occurs due to anaerobic muscle metabolism.</li><li>• correct</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• The symptoms and presentations of peripheral arterial disease , includes the association of intermittent claudication with chronic lower limb arterial stenosis and the impact of collateral circulation on symptom severity.</li><li>• symptoms and presentations of peripheral arterial disease</li><li>• association of intermittent claudication with chronic lower limb arterial stenosis</li><li>• impact of collateral circulation</li><li>• The severity of the symptoms relates to the size of the vessel occluded and whether the stenosis or occlusion occurs suddenly (acute) in a previously normal artery or gradually (chronic) with progressive narrowing of the artery over time. In chronic stenosis symptoms may be reduced despite being affected by significant steno-occlusive disease as a result of the development of a collateral circulation that provides an alternative, albeit less effective, route for blood to reach the target tissue/organ. The most common cause of peripheral arterial disease is atherosclerosis. Other causes include thromboembolic disease and sometimes trauma. The most common symptom of chronic lower limb arterial stenosis is intermittent claudication, which occurs due to anaerobic muscle metabolism.</li><li>• The severity of the symptoms relates to the size of the vessel occluded and whether the stenosis or occlusion occurs suddenly (acute) in a previously normal artery or gradually (chronic) with progressive narrowing of the artery over time.</li><li>• severity of the symptoms</li><li>• size of the vessel occluded</li><li>• stenosis or occlusion occurs suddenly</li><li>• In chronic stenosis symptoms may be reduced despite being affected by significant steno-occlusive disease as a result of the development of a collateral circulation that provides an alternative, albeit less effective, route for blood to reach the target tissue/organ.</li><li>• chronic stenosis</li><li>• reduced despite being affected by significant</li><li>• steno-occlusive</li><li>• disease</li><li>• development of a collateral circulation</li><li>• The most common cause of peripheral arterial disease is atherosclerosis. Other causes include thromboembolic disease and sometimes trauma.</li><li>• The most common symptom of chronic lower limb arterial stenosis is intermittent claudication, which occurs due to anaerobic muscle metabolism.</li><li>• most common symptom of chronic lower limb arterial stenosis is intermittent claudication,</li><li>• Other features</li><li>• Other features</li><li>• Rest pain Ulceration Gangrene Dependent rubor (sunset foot) Absent / diminished arterial pulsation Slow capillary refill Arterial bruit</li><li>• Rest pain</li><li>• Ulceration</li><li>• Gangrene</li><li>• Dependent rubor (sunset foot)</li><li>• Absent / diminished arterial pulsation</li><li>• Slow capillary refill</li><li>• Arterial bruit</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 997</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Page 997</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient came to the surgical OPD with complaints of lower limb pain. After eliciting complete history, the surgeon considers the first differential to be intermittent claudication due to arterial disorder. Which of the following features would have prompted him to consider this differential? Brought on by walking Present on taking first step Relieved on resting for 5 mins Distance that patient is able to walk without stopping greatly varying every day.", "options": [{"label": "A", "text": "a b c", "correct": false}, {"label": "B", "text": "a c", "correct": true}, {"label": "C", "text": "a d", "correct": false}, {"label": "D", "text": "b c d", "correct": false}], "correct_answer": "B. a c", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) a c</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Intermittent claudication is classically described as debilitating cramp like pain in the muscles due to anaerobic muscle metabolism . The characteristic features of intermittent claudication are as follows-</li><li>• Intermittent claudication</li><li>• cramp like pain</li><li>• muscles due to anaerobic muscle metabolism</li><li>• Brought on by walking (option A) Not present on taking the first step (unlike osteoarthritis) (option B) Relieved by rest in both the standing and sitting positions, usually within 5 minutes (Option C) (unlike nerve compression from a lumbar intervertebral disc prolapse or osteoarthritis of the spine or spinal stenosis, which are typically relieved only when resting in the sitting position for longer than 5 minutes). The distance that a patient is able to walk without stopping varies (claudication distance) only slightly from day to day (Option D) .</li><li>• Brought on by walking (option A)</li><li>• (option A)</li><li>• Not present on taking the first step (unlike osteoarthritis) (option B)</li><li>• (option B)</li><li>• Relieved by rest in both the standing and sitting positions, usually within 5 minutes (Option C) (unlike nerve compression from a lumbar intervertebral disc prolapse or osteoarthritis of the spine or spinal stenosis, which are typically relieved only when resting in the sitting position for longer than 5 minutes).</li><li>• (Option C)</li><li>• The distance that a patient is able to walk without stopping varies (claudication distance) only slightly from day to day (Option D) .</li><li>• (Option D)</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• The muscle group affected by claudication is classically one anatomical level below the level of arterial disease and is usually felt in the posterior calf as the superficial femoral artery is the most commonly affected artery (70% of cases). Aortoiliac disease (30% of cases) may cause thigh or buttock claudication . Leriche ’ s syndrome is buttock claudication combined with sexual impotence, which is secondary to arterial insufficiency.</li><li>• The muscle group affected by claudication is classically one anatomical level below the level of arterial disease and is usually felt in the posterior calf as the superficial femoral artery is the most commonly affected artery (70% of cases).</li><li>• the superficial femoral artery is the most commonly affected artery (70% of cases).</li><li>• Aortoiliac disease (30% of cases) may cause thigh or buttock claudication . Leriche ’ s syndrome is buttock claudication combined with sexual impotence, which is secondary to arterial insufficiency.</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 998</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Page 998</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is not a characteristic feature of rest pain that is seen in peripheral arterial occlusive diseases?", "options": [{"label": "A", "text": "Typical affects foot / calf", "correct": false}, {"label": "B", "text": "Worse at night", "correct": false}, {"label": "C", "text": "Pressure of bedclothes may exacerbate the pain", "correct": false}, {"label": "D", "text": "Relieved on limb elevation", "correct": true}], "correct_answer": "D. Relieved on limb elevation", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Relieved on limb elevation</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Typically affects calf / foot</li><li>• Option A.</li><li>• Typically affects calf / foot</li><li>• Option B. Worse at night and lessened by hanging the foot out of the bed or by sleeping in a chair (effects of gravity restored)</li><li>• Option B.</li><li>• Worse at night</li><li>• lessened by hanging the foot out of the bed</li><li>• Option C. E ven pressure of bedclothes may exacerbate the pain</li><li>• Option C. E</li><li>• ven pressure of bedclothes may exacerbate the pain</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Boyd classification of intermittent claudication -</li><li>• Boyd classification of intermittent claudication</li><li>• Class I - Pain on walking but decreases on continuation of walking (due to release of local vasodilators) Class II - Pain on walking but patient continues to walk with limp Class III - Pain forces patient to stop walking. Pain is relieved on rest.</li><li>• Class I - Pain on walking but decreases on continuation of walking (due to release of local vasodilators)</li><li>• Class I</li><li>• Class II - Pain on walking but patient continues to walk with limp</li><li>• Class II</li><li>• Class III - Pain forces patient to stop walking. Pain is relieved on rest.</li><li>• Class III</li><li>• Rest pain is not included in Boyd classification . It is also called ‘cry of the dying nerves’ (due to ischemia).</li><li>• Rest pain is not included in Boyd classification</li><li>• ‘cry of the dying nerves’</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 999</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Page 999</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "An elderly smoker patient with complaints of rest pain, which is worse at night. The following examination findings are noted: blackening of right great toe, absent dorsalis pedis, anterior and posterior tibial pulsations. Which of the following findings will not be seen in this patient?", "options": [{"label": "A", "text": "Increased capillary refill time", "correct": false}, {"label": "B", "text": "Pallor of limb on elevation that changes to dusky rubor on hanging down the foot", "correct": false}, {"label": "C", "text": "Lipodermatosclerosis", "correct": true}, {"label": "D", "text": "Loss of hair, brittle nails", "correct": false}], "correct_answer": "C. Lipodermatosclerosis", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Lipodermatosclerosis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A. Increased capillary refill time. Correct . In peripheral arterial disease (PAD), there is reduced blood flow, leading to an increased capillary refill time. Normally, it should be &lt; 3 seconds if circulation is intact.</li><li>• Option A. Increased capillary refill time. Correct</li><li>• Option B. Pallor of limb on elevation that changes to dusky rubor on hanging down the foot. Correct . This describes the dependent rubor, a characteristic sign in PAD where the limb appears pale on elevation and becomes dusky or reddish on dependency.</li><li>• Option B. Pallor of limb on elevation that changes to dusky rubor on hanging down the foot. Correct</li><li>• Option D. Loss of hair, brittle nails. Correct . Reduced blood flow in PAD can lead to ischemic changes, including loss of hair and brittle nails.</li><li>• Option D. Loss of hair, brittle nails. Correct</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• The examination findings associated with peripheral arterial disease include increased capillary refill time, dependent rubor, and ischemic changes such as loss of hair and brittle nails , while distinguishing them from features seen in venous insufficiency.</li><li>• examination findings associated with peripheral arterial disease</li><li>• increased capillary refill time, dependent rubor, and ischemic changes</li><li>• loss of hair and brittle nails</li><li>• Examination findings in PAD -</li><li>• Examination findings in PAD</li><li>• Inspection-</li><li>• Inspection-</li><li>• Arterial ulcer / dry gangrene Loss of hair, dry skin, brittle nails Loss of subcutaneous fat and muscle Dependent rubor- Pallor of limb on elevation that changes to dusky rubor on hanging down the foot. Also called sunset foot sign.</li><li>• Arterial ulcer / dry gangrene</li><li>• Loss of hair, dry skin, brittle nails</li><li>• Loss of subcutaneous fat and muscle</li><li>• Dependent rubor- Pallor of limb on elevation that changes to dusky rubor on hanging down the foot. Also called sunset foot sign.</li><li>• Palpation:</li><li>• Palpation:</li><li>• Increased capillary refill time Absent/diminished arterial pulsations distal to site of obstruction</li><li>• Increased capillary refill time</li><li>• Absent/diminished arterial pulsations distal to site of obstruction</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 999</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Page 999</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "On examination on a patient of suspected Peripheral Arterial Disease, the doctor was seen to be performing the action shown in the given image. Which artery is he likely trying to palpate?", "options": [{"label": "A", "text": "Anterior tibial", "correct": false}, {"label": "B", "text": "Posterior tibial", "correct": true}, {"label": "C", "text": "Dorsalis pedis", "correct": false}, {"label": "D", "text": "Popliteal", "correct": false}], "correct_answer": "B. Posterior tibial", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/27/untitled-511.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/13/screenshot-2023-12-13-112211.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/30/vascular-surgery-19.jpeg"], "explanation": "<p><strong>Ans. B)</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Internal carotid artery is not usually palpable except in tonsillar fossa of people who have undergone tonsillectomy.</li><li>• Internal carotid artery</li><li>• not usually palpable except in tonsillar fossa</li><li>• Ref : A Manual on Clinical Surgery by S. Das Page 85-87</li><li>• Ref</li><li>• : A Manual on Clinical Surgery by S. Das Page 85-87</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Find the incorrect match regarding Ankle Brachial Pressure Index (ABPI):", "options": [{"label": "A", "text": "Normal - 0.9-1.2", "correct": false}, {"label": "B", "text": "Diabetes mellitus - 1.5", "correct": false}, {"label": "C", "text": "Limb threatening ischemia- 0.5", "correct": true}, {"label": "D", "text": "Drop in resting ABI after exercise in patient of PAD - 25%", "correct": false}], "correct_answer": "C. Limb threatening ischemia- 0.5", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Limb threatening ischemia- 0.5</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Normal - 0.9-1.2. Correct . The normal resting ABI is indeed 0.9–1.4.</li><li>• Option A. Normal - 0.9-1.2. Correct</li><li>• Option B. Diabetes mellitus - 1.5. Correct . Artificially high ABI readings (&gt;1.4) can occur in patients with diabetes mellitus due to media sclerosis and calcification of the arterial wall, causing vessel incompressibility.</li><li>• Option B. Diabetes mellitus - 1.5. Correct</li><li>• Option D. Drop in resting ABI after exercise in patients with PAD - 25%. A drop in the resting ABI of &gt;20% after exercise is indicative of flow-limiting arterial disease.</li><li>• Option D. Drop in resting ABI after exercise in patients with PAD - 25%.</li><li>• Educationnel objective :</li><li>• Educationnel objective :</li><li>• Understanding the correct ranges of Ankle-Brachial Pressure Index (ABI) and recognizing the significance of a drop in ABI after exercise in patients with peripheral arterial disease.</li><li>• correct ranges of Ankle-Brachial Pressure Index</li><li>• recognizing the significance of a drop in ABI after exercise</li><li>• Ankle–Brachial pressure Index (ABI) is the ratio of the systolic pressure at the ankle to that in the ipsilateral arm . The highest pressure in the dorsalis pedis, posterior tibial or peroneal artery serves as the numerator, with the highest brachial systolic pressure being the denominator. The normal resting ABI is 0.9–1.4. Values below 0.9 indicate a haemodynamically significant arterial lesion . A value &lt; 0.4 suggests CLTI (chronic limb threatening ischemia). A drop in the resting ABI of &gt;20% after exercise is indicative of flow-limiting arterial disease. Artificially high ABI readings (&gt;1.4) can be caused by media sclerosis and calcification of the arterial wall, causing vessel incompressibility and a falsely elevated ABI; this pattern of disease typically occurs in patients with diabetes mellitus.</li><li>• Ankle–Brachial pressure Index (ABI) is the ratio of the systolic pressure at the ankle to that in the ipsilateral arm . The highest pressure in the dorsalis pedis, posterior tibial or peroneal artery serves as the numerator, with the highest brachial systolic pressure being the denominator. The normal resting ABI is 0.9–1.4. Values below 0.9 indicate a haemodynamically significant arterial lesion . A value &lt; 0.4 suggests CLTI (chronic limb threatening ischemia). A drop in the resting ABI of &gt;20% after exercise is indicative of flow-limiting arterial disease. Artificially high ABI readings (&gt;1.4) can be caused by media sclerosis and calcification of the arterial wall, causing vessel incompressibility and a falsely elevated ABI; this pattern of disease typically occurs in patients with diabetes mellitus.</li><li>• Ankle–Brachial pressure Index</li><li>• ratio of the systolic pressure at the ankle</li><li>• ipsilateral arm</li><li>• The normal resting ABI is 0.9–1.4. Values below 0.9 indicate a haemodynamically significant arterial lesion . A value &lt; 0.4 suggests CLTI (chronic limb threatening ischemia). A drop in the resting ABI of &gt;20% after exercise is indicative of flow-limiting arterial disease. Artificially high ABI readings (&gt;1.4) can be caused by media sclerosis and calcification of the arterial wall, causing vessel incompressibility and a falsely elevated ABI; this pattern of disease typically occurs in patients with diabetes mellitus.</li><li>• The normal resting ABI is 0.9–1.4.</li><li>• Values below 0.9 indicate a haemodynamically significant arterial lesion .</li><li>• A value &lt; 0.4 suggests CLTI (chronic limb threatening ischemia).</li><li>• A drop in the resting ABI of &gt;20% after exercise is indicative of flow-limiting arterial disease.</li><li>• Artificially high ABI readings (&gt;1.4) can be caused by media sclerosis and calcification of the arterial wall, causing vessel incompressibility and a falsely elevated ABI; this pattern of disease typically occurs in patients with diabetes mellitus.</li><li>• Toe (digital) arteries are rarely affected by sclerosis and a toe–brachial pressure index (TBI) in combination with ABI is advocated as a more reliable diagnostic tool for the detection of significant large-vessel steno-occlusive disease in patients with DM. A TBI less than 0.6 suggests a significant arterial lesion that may have been overlooked if ABI was used in isolation.</li><li>• Toe (digital) arteries are rarely affected by sclerosis and a toe–brachial pressure index (TBI) in combination with ABI is advocated as a more reliable diagnostic tool for the detection of significant large-vessel steno-occlusive disease in patients with DM. A TBI less than 0.6 suggests a significant arterial lesion that may have been overlooked if ABI was used in isolation.</li><li>• Toe</li><li>• arteries are rarely affected by sclerosis and a toe–brachial pressure index</li><li>• in combination with ABI is advocated as a more reliable diagnostic tool for the detection</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1001</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1001</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient came with complaints of cramping pain in right lower limb which worsened on walking and was relieved by rest. He also had loss of hair, dry skin, brittle nails on right lower limb. What is your next step?", "options": [{"label": "A", "text": "Duplex Doppler ultrasound", "correct": true}, {"label": "B", "text": "CT angiography", "correct": false}, {"label": "C", "text": "Digital subtraction angiogram", "correct": false}, {"label": "D", "text": "Arterial bypass grafting", "correct": false}], "correct_answer": "A. Duplex Doppler ultrasound", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/27/untitled-516.jpg"], "explanation": "<p><strong>Ans. A) Duplex Doppler ultrasound</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. CT angiography. Incorrect . While CT angiography is a valuable imaging modality , it is not the first-line investigation for evaluating peripheral arterial disease. Duplex Doppler ultrasound is preferred initially.</li><li>• Option B. CT angiography. Incorrect</li><li>• CT angiography is a valuable imaging modality</li><li>• not the first-line investigation</li><li>• Option C. Digital subtraction angiogram. Incorrect. Digital subtraction angiography (DSA) is an invasive procedure and is not the first choice. It is usually performed when planning an intervention like angioplasty.</li><li>• Option C. Digital subtraction angiogram.</li><li>• Digital subtraction angiography</li><li>• an invasive procedure</li><li>• Option D. Arterial bypass grafting. Incorrect. Arterial bypass grafting is a treatment option, not a diagnostic step . Diagnostic imaging is needed before considering surgical interventions.</li><li>• Option D. Arterial bypass grafting.</li><li>• Arterial bypass grafting is a treatment option, not a diagnostic step</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• The appropriate initial diagnostic step is Duplex Doppler ultrasound , in a patient with suspected peripheral arterial disease based on clinical symptoms and findings .</li><li>• appropriate initial diagnostic step is Duplex Doppler ultrasound</li><li>• patient with suspected peripheral arterial disease</li><li>• clinical symptoms and findings</li><li>• Limitation: When DUS inadequately visualises or quantifies the level of disease within an arterial segment, an alternative imaging modality, e.g., digital subtraction percutaneous angiography (DSA) or computed tomography angiography (CTA), may be undertaken to delineate the anatomy and extent of disease.</li><li>• Limitation:</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1001</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1001</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Classify the following statements about transluminal angioplasty as true (T) or false (F): It is contraindicated in people with rest pain. It is most successful in treating below the knee lesions. Satisfactory dilatation of the lesion is confirmed by performing an angiogram.", "options": [{"label": "A", "text": "T T F", "correct": false}, {"label": "B", "text": "F F T", "correct": true}, {"label": "C", "text": "T F T", "correct": false}, {"label": "D", "text": "T F F", "correct": false}], "correct_answer": "B. F F T", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/13/picture1_qvD5V1G.jpg"], "explanation": "<p><strong>Ans. B) F F T</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• It is contraindicated in people with rest pain. False. Transluminal angioplasty is not contraindicated in people with rest pain . In fact, it can be a beneficial intervention for improving blood flow and relieving symptoms.</li><li>• It is contraindicated in people with rest pain.</li><li>• Transluminal angioplasty</li><li>• not contraindicated in people with rest pain</li><li>• It is most successful in treating below the knee lesions. False. Transluminal angioplasty is generally more successful in treating lesions above the knee . Below-the-knee lesions, especially in smaller vessels, may have lower success rates due to early stent occlusion</li><li>• It is most successful in treating below the knee lesions.</li><li>• Transluminal angioplasty</li><li>• generally more successful in treating lesions above the knee</li><li>• Satisfactory dilatation of the lesion is confirmed by performing an angiogram . True. Satisfactory dilatation of the lesion is confirmed by performing an angiogram , which allows visualization of the treated vessel and ensures that the blood flow has improved.</li><li>• Satisfactory dilatation of the lesion is confirmed by performing an angiogram</li><li>• Satisfactory dilatation of the lesion is confirmed by performing an angiogram</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Transluminal angioplasty and stenting -</li><li>• Transluminal angioplasty and stenting</li><li>• Arterial occlusive disease may be treated by inserting a balloon catheter into an artery and inflating it within a stenosed or occluded segment . This technique is suitable for patients with claudication, rest pain or tissue necrosis. Following percutaneous femoral artery puncture under local anesthetic, a guide-wire is inserted and negotiated through the stenosis or occlusion under fluoroscopic control. A balloon catheter is positioned within the lesion over the guide-wire and inflated at high pressure for approximately 30 seconds. Satisfactory dilatation of the lesion is confirmed by performing an angiogram . Percutaneous transluminal angioplasty (PTA) has proved very successful in dilating the iliac and femoropopliteal segments; the results below the knee are less successful. If the vessel fails to stay adequately dilated (often caused by elastic recoil of the artery), it may be possible to hold the lumen open using a metallic stent. This may be introduced on a balloon catheter and expanded by balloon inflation. Alternatively, a self-expanding stent may be used; this is contained inside a plastic sheath and deployed by withdrawal of the sheath.</li><li>• Arterial occlusive disease may be treated by inserting a balloon catheter into an artery and inflating it within a stenosed or occluded segment . This technique is suitable for patients with claudication, rest pain or tissue necrosis.</li><li>• Arterial occlusive disease</li><li>• treated by inserting a balloon catheter into an artery</li><li>• inflating it within a stenosed or occluded segment</li><li>• Following percutaneous femoral artery puncture under local anesthetic, a guide-wire is inserted and negotiated through the stenosis or occlusion under fluoroscopic control. A balloon catheter is positioned within the lesion over the guide-wire and inflated at high pressure for approximately 30 seconds.</li><li>• Satisfactory dilatation of the lesion is confirmed by performing an angiogram .</li><li>• Satisfactory dilatation of the lesion is confirmed by performing an angiogram</li><li>• Percutaneous transluminal angioplasty (PTA) has proved very successful in dilating the iliac and femoropopliteal segments; the results below the knee are less successful.</li><li>• If the vessel fails to stay adequately dilated (often caused by elastic recoil of the artery), it may be possible to hold the lumen open using a metallic stent. This may be introduced on a balloon catheter and expanded by balloon inflation. Alternatively, a self-expanding stent may be used; this is contained inside a plastic sheath and deployed by withdrawal of the sheath.</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1004</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1004</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient with superficial femoral artery obstruction was planned for bypass grafting. Which of the following is the graft material of choice?", "options": [{"label": "A", "text": "Short Saphenous vein", "correct": false}, {"label": "B", "text": "PTFE", "correct": false}, {"label": "C", "text": "Great Saphenous vein", "correct": true}, {"label": "D", "text": "Internal mammary artery", "correct": false}], "correct_answer": "C. Great Saphenous vein", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Great Saphenous vein</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Short Saphenous vein. The short saphenous vein is not commonly used for arterial bypass grafting . It is more commonly utilized when other grafts are unavailable.</li><li>• Option A. Short Saphenous vein.</li><li>• not commonly used for arterial bypass grafting</li><li>• Option B. PTFE (Polytetrafluoroethylene). PTFE is a synthetic graft material that can be used in bypass grafting when autologous veins are not available . However, autologous veins are generally preferred for better long-term outcomes.</li><li>• Option B. PTFE (Polytetrafluoroethylene).</li><li>• synthetic graft material that can be used in bypass grafting when autologous veins are not available</li><li>• Option D. Internal mammary artery. The internal mammary artery is typically used in coronary artery bypass grafting (CABG) procedures , not for peripheral arterial bypass grafting.</li><li>• Option D. Internal mammary artery.</li><li>• used in coronary artery bypass grafting</li><li>• procedures</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• The preferred autologous graft material for peripheral arterial bypass grafting , is the great saphenous vein due to its favorable outcomes.</li><li>• autologous graft material for peripheral arterial bypass grafting</li><li>• great saphenous vein due to its favorable outcomes.</li><li>• Autologous great saphenous vein (GSV) gives the best results and can be used reversed or in situ after valve disruption . If the GSV is not available from either leg, the lesser saphenous or arm veins may be used. If no vein is available, a prosthetic polytetrafluoroethylene (PTFE) graft may be employed.</li><li>• Autologous great saphenous vein</li><li>• best results and can be used reversed or in situ after valve disruption</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1005</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1005</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Match the correct bypass options that you would choose for the given scenarios:", "options": [{"label": "A", "text": "a-1 b-2 c-3", "correct": false}, {"label": "B", "text": "a-2 b-1 c-3", "correct": false}, {"label": "C", "text": "a-3 b-1 c-2", "correct": false}, {"label": "D", "text": "a-2 b-3 c-1", "correct": true}], "correct_answer": "D. a-2 b-3 c-1", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/13/screenshot-2023-12-13-123611.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/13/picture2_TttlK4g.jpg"], "explanation": "<p><strong>Ans. D) a-2 b-3 c-1</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient presented with transient blindness in left eye. On examination, a carotid bruit was heard. Investigations revealed 60% stenosis in carotid artery. What will be the best treatment option in this case?", "options": [{"label": "A", "text": "Bypass grafting", "correct": false}, {"label": "B", "text": "Angiography and stenting", "correct": false}, {"label": "C", "text": "Carotid Endarterectomy", "correct": true}, {"label": "D", "text": "No treatment required", "correct": false}], "correct_answer": "C. Carotid Endarterectomy", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Carotid Endarterectomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Bypass grafting. Bypass grafting is not the primary treatment for carotid artery stenosis . It is more commonly used for coronary or peripheral artery disease.</li><li>• Option A. Bypass grafting.</li><li>• not the primary treatment for carotid artery stenosis</li><li>• Option B. Angiography and stenting. While angiography and stenting may be considered in some cases , carotid endarterectomy is generally preferred for symptomatic patients with significant carotid stenosis.</li><li>• Option B. Angiography and stenting.</li><li>• angiography and stenting may be considered in some cases</li><li>• Option D. No treatment required. With significant carotid stenosis and associated symptoms, such as transient blindness , intervention is typically warranted to reduce the risk of stroke.</li><li>• Option D. No treatment required.</li><li>• carotid stenosis</li><li>• associated symptoms, such as transient blindness</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Carotid endarterectomy is the preferred treatment for symptomatic patients with 50% or greater carotid stenosis and associated neurological symptoms , providing a reduction in the risk of stroke . Indications for carotid endarterectomy in symptomatic patients 50% or greater carotid stenosis are:</li><li>➤ Carotid endarterectomy</li><li>➤ preferred treatment for symptomatic patients with 50% or greater carotid stenosis</li><li>➤ neurological symptoms</li><li>➤ reduction in the risk of stroke</li><li>➤ Ipsilateral amaurosis fugax or monocular blindness Contralateral facial paralysis or paraesthesia Arm/leg paralysis or paraesthesia Hemianopia Dysphasia (if dominant hemisphere) Sensory or visual inattention/neglect</li><li>➤ Ipsilateral amaurosis fugax or monocular blindness</li><li>➤ Contralateral facial paralysis or paraesthesia</li><li>➤ Arm/leg paralysis or paraesthesia</li><li>➤ Hemianopia</li><li>➤ Dysphasia (if dominant hemisphere)</li><li>➤ Sensory or visual inattention/neglect</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1008</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1008</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A poorly controlled diabetic patient presented with the following picture. There was crepitus on palpation. All the following statements are true about this condition except?", "options": [{"label": "A", "text": "Occurs due to gradual slowing of blood flow and desiccation of tissues", "correct": true}, {"label": "B", "text": "Has superadded putrefaction", "correct": false}, {"label": "C", "text": "The black colour is due to iron sulphide formation from hemoglobin", "correct": false}, {"label": "D", "text": "Requires urgent debridement / amputation", "correct": false}], "correct_answer": "A. Occurs due to gradual slowing of blood flow and desiccation of tissues", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/27/untitled-519.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. A) Occurs due to gradual slowing of blood flow and desiccation of tissues</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. Has superadded putrefaction. True . Wet gangrene is associated with bacterial infection and putrefaction, leading to the production of gas and the characteristic crepitus.</li><li>• Option B.</li><li>• Has superadded putrefaction.</li><li>• True</li><li>• Option C . The black colour is due to iron sulphide formation from hemoglobin. True . The black color in gangrene results from the breakdown of hemoglobin and the formation of iron sulphide.</li><li>• Option C</li><li>• The black colour is due to iron sulphide formation from hemoglobin.</li><li>• True</li><li>• Option D. Requires urgent debridement/amputation. True . Wet gangrene is a surgical emergency, and urgent debridement or amputation is necessary to prevent the spread of infection and sepsis.</li><li>• Option D.</li><li>• Requires urgent debridement/amputation.</li><li>• True</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Wet gangrene is characterized by rapid tissue necrosis , bacterial infection , and putrefaction , requires urgent surgical intervention such as debridement or amputation to prevent complications .</li><li>➤ Wet gangrene</li><li>➤ rapid tissue necrosis</li><li>➤ bacterial infection</li><li>➤ putrefaction</li><li>➤ urgent surgical intervention such as debridement or amputation to prevent complications</li><li>➤ Gangrene refers to the death of macroscopic portions of tissue, which turns black because of the breakdown of haemoglobin and the formation of iron sulphide. It usually affects the most distal part of a limb because of arterial obstruction (from thrombosis, embolus or arteritis). Dry gangrene occurs when the tissues are desiccated by gradual slowing of the blood stream; it is typically the result of atheromatous occlusion of arteries. Wet gangrene occurs when superadded infection and putrefaction are present. Crepitus may be palpated as a result of infection by gas-forming organisms, commonly in diabetic foot problems, and should be considered a surgical emergency with urgent tissue debridement or amputation required.</li><li>➤ Gangrene refers to the death of macroscopic portions of tissue, which turns black because of the breakdown of haemoglobin and the formation of iron sulphide. It usually affects the most distal part of a limb because of arterial obstruction (from thrombosis, embolus or arteritis).</li><li>➤ Dry gangrene occurs when the tissues are desiccated by gradual slowing of the blood stream; it is typically the result of atheromatous occlusion of arteries.</li><li>➤ Wet gangrene occurs when superadded infection and putrefaction are present. Crepitus may be palpated as a result of infection by gas-forming organisms, commonly in diabetic foot problems, and should be considered a surgical emergency with urgent tissue debridement or amputation required.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1008</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1008</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "An athlete presented with an episode of syncope after his arm exercise routine. The doctor suspects subclavian steal syndrome. Regarding the same, identify these statements as true / false: Occurs due to occlusion of third part of subclavian artery There is reversal of flow in contralateral vertebral artery leading to cerebral ischemia and syncope", "options": [{"label": "A", "text": "T T", "correct": false}, {"label": "B", "text": "F F", "correct": true}, {"label": "C", "text": "T F", "correct": false}, {"label": "D", "text": "F T", "correct": false}], "correct_answer": "B. F F", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/30/vascular-surgery-12.jpg"], "explanation": "<p><strong>Ans. B) F F</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• About subclavian steal syndrome:</li><li>• About subclavian steal syndrome:</li><li>• Occurs due to occlusion of the third part of the subclavian artery: This statement is false . Subclavian steal syndrome typically occurs due to atherosclerotic disease at the origin/first part of the subclavian artery, not the third part. There is a reversal of flow in the contralateral vertebral artery leading to cerebral ischemia and syncope: False . In subclavian steal syndrome , blood flow is reversed in the ipsilateral vertebral artery to supply the exercising arm , which can lead to cerebral ischemia and syncope.</li><li>• Occurs due to occlusion of the third part of the subclavian artery: This statement is false . Subclavian steal syndrome typically occurs due to atherosclerotic disease at the origin/first part of the subclavian artery, not the third part.</li><li>• Occurs due to occlusion of the third part of the subclavian artery:</li><li>• This statement is false . Subclavian steal syndrome typically occurs due to atherosclerotic disease at the origin/first part of the subclavian artery, not the third part.</li><li>• This statement is false . Subclavian steal syndrome typically occurs due to atherosclerotic disease at the origin/first part of the subclavian artery, not the third part.</li><li>• false</li><li>• Subclavian steal syndrome</li><li>• occurs due to atherosclerotic disease</li><li>• origin/first part</li><li>• There is a reversal of flow in the contralateral vertebral artery leading to cerebral ischemia and syncope: False . In subclavian steal syndrome , blood flow is reversed in the ipsilateral vertebral artery to supply the exercising arm , which can lead to cerebral ischemia and syncope.</li><li>• There is a reversal of flow in the contralateral vertebral artery leading to cerebral ischemia and syncope:</li><li>• False . In subclavian steal syndrome , blood flow is reversed in the ipsilateral vertebral artery to supply the exercising arm , which can lead to cerebral ischemia and syncope.</li><li>• False . In subclavian steal syndrome , blood flow is reversed in the ipsilateral vertebral artery to supply the exercising arm , which can lead to cerebral ischemia and syncope.</li><li>• False</li><li>• subclavian steal syndrome</li><li>• blood flow is reversed in the ipsilateral vertebral artery</li><li>• supply the exercising arm</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Subclavian steal syndrome may occur if the first part of the subclavian artery is occluded . Arm exercise causes syncope because of reversed flow in the vertebral artery (subclavian steal), leading to cerebral ischaemia . It can be treated by angioplasty or surgery and is rare.</li><li>➤ Subclavian steal syndrome</li><li>➤ first part of the subclavian artery is occluded</li><li>➤ Arm exercise causes syncope</li><li>➤ reversed flow in the vertebral artery</li><li>➤ cerebral ischaemia</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1008</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1008</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Regarding differences between dry and wet gangrene, which of the following is true?", "options": [{"label": "A", "text": "Wet gangrene- clear cut line of demarcation", "correct": false}, {"label": "B", "text": "Dry gangrene- multiple skip lesions", "correct": false}, {"label": "C", "text": "Wet gangrene- multiple skip lesions", "correct": true}, {"label": "D", "text": "Dry gangrene- sudden loss of blood supply", "correct": false}], "correct_answer": "C. Wet gangrene- multiple skip lesions", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/13/picture3_2zXd8TF.jpg"], "explanation": "<p><strong>Ans. C) Wet gangrene- multiple skip lesion</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Wet gangrene - clear-cut line of demarcation. This statement is false . Wet gangrene is characterized by the absence of a clear-cut line of demarcation due to the spread of infection into neighbouring tissues.</li><li>• Option A: Wet gangrene - clear-cut line of demarcation.</li><li>• false</li><li>• absence of a clear-cut line of demarcation due to the spread of infection into neighbouring tissues.</li><li>• Option B: Dry gangrene - multiple skip lesions. False. Dry gangrene is associated with a clear-cut line of demarcation , not multiple skip lesions.</li><li>• Option B: Dry gangrene - multiple skip lesions.</li><li>• Dry gangrene is associated with a clear-cut</li><li>• line of demarcation</li><li>• Option D: Dry gangrene - sudden loss of blood supply. False. Dry gangrene is associated with a gradual slowing of blood flow , not a sudden loss.</li><li>• Option D: Dry gangrene - sudden loss of blood supply.</li><li>• Dry gangrene</li><li>• gradual slowing of blood flow</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ A clear-cut line of demarcation is seen in dry gangrene, due to development of a layer of granulation tissue, which separates viable from nonviable parts. In wet gangrene, the infection and suppuration extend into the neighbouring living tissues. The gangrene may suddenly appear as ‘ skip ’ areas further up the limb. These skip lesions may occur on the other side of the foot, on the heel, on the dorsum of the foot or even in the calf. Dry gangrene is due to gradual slowing of blood flow and desiccation of tissues while wet gangrene is often due to a sudden cutoff of blood supply/acute ischemia.</li><li>➤ A clear-cut line of demarcation is seen in dry gangrene, due to development of a layer of granulation tissue, which separates viable from nonviable parts.</li><li>➤ A clear-cut line of demarcation is seen in dry gangrene, due to development of a layer of granulation tissue, which separates viable from nonviable parts.</li><li>➤ In wet gangrene, the infection and suppuration extend into the neighbouring living tissues.</li><li>➤ The gangrene may suddenly appear as ‘ skip ’ areas further up the limb. These skip lesions may occur on the other side of the foot, on the heel, on the dorsum of the foot or even in the calf.</li><li>➤ Dry gangrene is due to gradual slowing of blood flow and desiccation of tissues while wet gangrene is often due to a sudden cutoff of blood supply/acute ischemia.</li><li>➤ Dry gangrene of great toe with line of demarcation</li><li>➤ Dry gangrene of great toe with line of demarcation</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1008</li><li>➤ Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1008</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient who is a known case of atrial fibrillation, came with complaints of acute left lower limb pain for the last 12 hours. The surgeon suspects acute limb ischemia. All the following statements are true about it except:", "options": [{"label": "A", "text": "Ischemia of 12 hours duration can be easily treated with no chances of limb loss.", "correct": true}, {"label": "B", "text": "Other clinical features include pallor, pulse lessness and paraesthesia.", "correct": false}, {"label": "C", "text": "Motor loss can occur as the condition progresses.", "correct": false}, {"label": "D", "text": "Embolectomy / thrombolysis are the treatment options.", "correct": false}], "correct_answer": "A. Ischemia of 12 hours duration can be easily treated with no chances of limb loss.", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Ischemia of 12 hours’ duration can be easily treated with no chances of limb loss.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. True. Other clinical features, such as pain, pallor, pulselessness, and paraesthesia, are characteristic in cases of acute limb ischemia.</li><li>• Option B. True.</li><li>• Option C. True . Motor loss can occur as the condition progresses, ranging from paraesthesia to complete loss of sensory and motor function due to ischemia of peripheral nerves.</li><li>• Option C. True</li><li>• Option D. True . Embolectomy and thrombolysis are viable treatment options for patients with limb emboli in acute limb ischemia.</li><li>• Option D. True</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Acute Limb Ischemia (ALI) is an emergency that requires rapid, accurate clinical assessment and emergency surgical treatment . ALI typically occurs as a result of embolic arterial occlusion or trauma.</li><li>➤ Acute Limb Ischemia</li><li>➤ emergency that requires rapid, accurate clinical assessment</li><li>➤ emergency surgical treatment</li><li>➤ Ischemia beyond 6 hours is usually irreversible and results in limb loss.</li><li>➤ Ischemia beyond 6 hours is usually irreversible and results in limb loss.</li><li>➤ Clinical features</li><li>➤ Clinical features</li><li>➤ Patients presenting with ALI secondary to embolism typically give no history of prior claudication and complain of the sudden development of severe pain or numbness of the limb. The skin is initially cold and pale, but as time progresses it slowly becomes mottled; first, non-fixed (blanching to pressure) and then fixed (non-blanching), indicating skin death. Neurological function deteriorates with time, progressing from paraesthesia to eventual complete loss of sensory and motor function, causing an insensate and paralysed limb. Thus, the 5 Ps of ALI include - pain, pallor, paraesthesia, pulselessness and paralysis.</li><li>➤ Patients presenting with ALI secondary to embolism typically give no history of prior claudication and complain of the sudden development of severe pain or numbness of the limb.</li><li>➤ The skin is initially cold and pale, but as time progresses it slowly becomes mottled; first, non-fixed (blanching to pressure) and then fixed (non-blanching), indicating skin death.</li><li>➤ Neurological function deteriorates with time, progressing from paraesthesia to eventual complete loss of sensory and motor function, causing an insensate and paralysed limb.</li><li>➤ Thus, the 5 Ps of ALI include - pain, pallor, paraesthesia, pulselessness and paralysis.</li><li>➤ 5 Ps of ALI include</li><li>➤ pain, pallor, paraesthesia, pulselessness</li><li>➤ paralysis.</li><li>➤ Treatment</li><li>➤ Treatment</li><li>➤ Because of the ensuing stasis, a thrombus can extend distally and proximally to the embolus. The immediate administration of 5000 U of heparin intravenously can reduce this extension and maintain patency of the surrounding (particularly the distal) vessels until the embolus can be treated. The relief of pain is essential because it is severe and constant.</li><li>➤ Embolectomy and thrombolysis are the treatments available for patients with limb emboli .</li><li>➤ Embolectomy</li><li>➤ and thrombolysis are the treatments available for patients with limb emboli</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1012.</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1012.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient of acute limb ischemia had an embolectomy procedure done. Regarding this scenario, choose the incorrect statement:", "options": [{"label": "A", "text": "Fogarty catheter is used commonly", "correct": false}, {"label": "B", "text": "An angiogram is done post the procedure.", "correct": false}, {"label": "C", "text": "Prophylactic fasciotomy to prevent postoperative compartment syndrome may be required.", "correct": false}, {"label": "D", "text": "The presence of palpable pulses in a patient with suspected compartment syndrome rules it out.", "correct": true}], "correct_answer": "D. The presence of palpable pulses in a patient with suspected compartment syndrome rules it out.", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/13/picture4_Cq0NK85.jpg"], "explanation": "<p><strong>Ans. D) The presence of palpable pulses in a patient with suspected compartment syndrome rules it out.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Fogarty catheter is used commonly: Correct . A Fogarty catheter is commonly used for embolectomy. It has a balloon tip that is inflated and withdrawn to remove obstructing material.</li><li>• Option A.</li><li>• Fogarty catheter is used commonly:</li><li>• Correct</li><li>• Option B. An angiogram is done post the procedure: Correct . An angiogram is often performed postoperatively to ensure that blood flow to the distal leg has been restored.</li><li>• Option B.</li><li>• An angiogram is done post the procedure:</li><li>• Correct</li><li>• Option C. Prophylactic fasciotomy to prevent postoperative compartment syndrome may be required: Correct . In limbs that have undergone revascularization, swelling can lead to compartment syndrome, and prophylactic fasciotomy may be necessary.</li><li>• Option C.</li><li>• Prophylactic fasciotomy to prevent postoperative compartment syndrome may be required:</li><li>• Correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ A Fogarty catheter is used for embolectomy . The catheter, with its balloon tip, is introduced both proximally and distally until it is deemed to have passed the limit of the clot. The balloon is inflated and the catheter withdrawn slowly, together with any obstructing material. The procedure is repeated until bleeding occurs. An angiogram may be performed in the operating theatre at the end of the procedure to ensure that flow to the distal leg has been restored. Postoperatively, heparin therapy is continued until long-term anticoagulation with warfarin is established to reduce the chance of further embolism. In limbs that have been subject to sudden ischaemia followed by revascularisation, oedema is likely due to reperfusion injury . Muscles swell within confined fascial compartments, and this can itself be a cause of tissue ischaemia, with both local muscle necrosis and nerve damage due to pressure and systemic effects such as renal failure secondary to the liberation of muscle breakdown products. The classical clinical picture is that of severe pain out of proportion with clinical findings that worsens with time despite appropriate analgesia. The patient often complains of numbness paraesthesia in the distribution of nerves running within the compartment. Examination of the limb reveals a tense compartment with passive flexion and extension of muscles causing pain. The presence of palpable pulses does not rule out compartment syndrome. The treatment is urgent compartment fasciotomy to release compression. The usual site for fasciotomy is the calf (especially the anterior tibial compartment), but compartment syndrome may occasionally affect the thigh, arm and foot. Liberal concomitant usage of calf with/without thigh fasciotomies following revascularisation of a prolonged ischaemic limb is advisable.</li><li>➤ A Fogarty catheter is used for embolectomy . The catheter, with its balloon tip, is introduced both proximally and distally until it is deemed to have passed the limit of the clot. The balloon is inflated and the catheter withdrawn slowly, together with any obstructing material. The procedure is repeated until bleeding occurs. An angiogram may be performed in the operating theatre at the end of the procedure to ensure that flow to the distal leg has been restored.</li><li>➤ Fogarty catheter is used for embolectomy</li><li>➤ Postoperatively, heparin therapy is continued until long-term anticoagulation with warfarin is established to reduce the chance of further embolism.</li><li>➤ heparin therapy is continued until long-term anticoagulation with warfarin</li><li>➤ In limbs that have been subject to sudden ischaemia followed by revascularisation, oedema is likely due to reperfusion injury . Muscles swell within confined fascial compartments, and this can itself be a cause of tissue ischaemia, with both local muscle necrosis and nerve damage due to pressure and systemic effects such as renal failure secondary to the liberation of muscle breakdown products.</li><li>➤ limbs that have been subject to sudden ischaemia followed by revascularisation, oedema is likely due to reperfusion injury</li><li>➤ The classical clinical picture is that of severe pain out of proportion with clinical findings that worsens with time despite appropriate analgesia. The patient often complains of numbness paraesthesia in the distribution of nerves running within the compartment. Examination of the limb reveals a tense compartment with passive flexion and extension of muscles causing pain.</li><li>➤ The presence of palpable pulses does not rule out compartment syndrome.</li><li>➤ The treatment is urgent compartment fasciotomy to release compression. The usual site for fasciotomy is the calf (especially the anterior tibial compartment), but compartment syndrome may occasionally affect the thigh, arm and foot. Liberal concomitant usage of calf with/without thigh fasciotomies following revascularisation of a prolonged ischaemic limb is advisable.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1013</li><li>➤ Ref</li><li>➤ :</li><li>➤ Bailey and Love’s Short Practice of Surgery 28th Edition Page 1013</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A factory worker was brought after accidental amputation of his right forearm due to a machinery related accident. Arrange the following in correct order of anastomosis during limb reimplantation: Artery Bone Nerves Flexor tendon Extensor tendon", "options": [{"label": "A", "text": "1 2 3 4 5", "correct": false}, {"label": "B", "text": "2 5 4 1 3", "correct": true}, {"label": "C", "text": "2 4 5 1 3", "correct": false}, {"label": "D", "text": "2 1 3 4 5", "correct": false}], "correct_answer": "B. 2 5 4 1 3", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) 2 5 4 1 3</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• The correct order in which structures are anastomosed during limb reimplantation is -</li><li>• correct order in which structures are anastomosed during limb reimplantation is</li><li>• Bone to bone- to stabilize the amputated segment with the proximal body part Extensor tendon Flexor tendon Artery Nerve Veins Skin</li><li>• Bone to bone- to stabilize the amputated segment with the proximal body part</li><li>• Extensor tendon</li><li>• Flexor tendon</li><li>• Artery</li><li>• Nerve</li><li>• Veins</li><li>• Skin</li><li>• Ref : Sabiston Textbook of Surgery 20th Edition Page 1997.</li><li>• Ref</li><li>• : Sabiston Textbook of Surgery 20th Edition Page 1997.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 65-year-old man was incidentally detected to have an abdominal aortic aneurysm of size 6 cm on USG. What will be the management in this case?", "options": [{"label": "A", "text": "Surveillance", "correct": false}, {"label": "B", "text": "Medical management", "correct": false}, {"label": "C", "text": "Elective surgery", "correct": true}, {"label": "D", "text": "Urgent laparotomy", "correct": false}], "correct_answer": "C. Elective surgery", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/13/picture5_xOuIJHj.jpg"], "explanation": "<p><strong>Ans. C) Elective surgery</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Surveillance : For asymptomatic abdominal aortic aneurysms &lt;55 mm in diameter, regular ultrasonography surveillance is indicated. This involves monitoring the aneurysm size over time to assess the risk of rupture.</li><li>• Option A. Surveillance</li><li>• asymptomatic abdominal aortic aneurysms &lt;55 mm in diameter,</li><li>• ultrasonography surveillance is indicated.</li><li>• Option B. Medical Management: Medical management alone is not a primary intervention for abdominal aortic aneurysms. Elective surgery is the preferred approach when specific criteria are met.</li><li>• Option B. Medical Management:</li><li>• not a primary intervention for abdominal aortic aneurysms.</li><li>• Option D. Urgent Laparotomy: Urgent laparotomy is not the first-line management for asymptomatic abdominal aortic aneurysms . Elective surgery is preferred in a controlled setting.</li><li>• Option D. Urgent Laparotomy:</li><li>• not the first-line management for asymptomatic abdominal aortic aneurysms</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Asymptomatic abdominal aortic aneurysms with a diameter &gt;55 mm should be considered for elective surgery to prevent rupture , and surveillance is indicated for aneurysms &lt;55 mm in diameter .</li><li>➤ Asymptomatic abdominal aortic aneurysms with a diameter &gt;55 mm</li><li>➤ elective surgery to prevent rupture</li><li>➤ surveillance is indicated for aneurysms &lt;55 mm in diameter</li><li>➤ Dilatations of localised segments of the arterial system are called aneurysms when there is a ≥50% increase in the diameter of the vessel; below 50% they are termed ectatic. Abdominal aortic aneurysm is by far the most common type of large-vessel aneurysm. It most commonly affects infra-renal aorta. An asymptomatic abdominal aortic aneurysm in an otherwise fit patient should be considered for repair if &gt;55 mm in diameter, measured by ultrasonography in the anteroposterior plane. The annual incidence of rupture rises exponentially as the aneurysm size passes 55 mm. The morphology of the aneurysm is best assessed by computed tomography (CT) scan. Management- elective operation once the maximum diameter is &gt;55 mm, provided there is no major comorbidity. Regular ultrasonography surveillance is indicated for asymptomatic aneurysms &lt;55 mm in diameter. Aneurysms smaller than 55 mm may be considered for repair if they are symptomatic or growing at a rate of &gt; 5mm/6 months of 10mm/year.</li><li>➤ Dilatations of localised segments of the arterial system are called aneurysms when there is a ≥50% increase in the diameter of the vessel; below 50% they are termed ectatic.</li><li>➤ Abdominal aortic aneurysm is by far the most common type of large-vessel aneurysm. It most commonly affects infra-renal aorta.</li><li>➤ An asymptomatic abdominal aortic aneurysm in an otherwise fit patient should be considered for repair if &gt;55 mm in diameter, measured by ultrasonography in the anteroposterior plane. The annual incidence of rupture rises exponentially as the aneurysm size passes 55 mm.</li><li>➤ The morphology of the aneurysm is best assessed by computed tomography (CT) scan.</li><li>➤ Management- elective operation once the maximum diameter is &gt;55 mm, provided there is no major comorbidity. Regular ultrasonography surveillance is indicated for asymptomatic aneurysms &lt;55 mm in diameter.</li><li>➤ Aneurysms smaller than 55 mm may be considered for repair if they are symptomatic or growing at a rate of &gt; 5mm/6 months of 10mm/year.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1017</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1017</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient with abdominal aortic aneurysm underwent the following procedure. Read the given statements about this procedure and find the correct one?", "options": [{"label": "A", "text": "Not suitable for infra renal aneurysms.", "correct": false}, {"label": "B", "text": "Patients who undergo this procedure require lifelong follow-up and surveillance.", "correct": true}, {"label": "C", "text": "Never done in case of ruptured aortic aneurysm.", "correct": false}, {"label": "D", "text": "They are preferred in young fit patients with aortic aneurysm", "correct": false}], "correct_answer": "B. Patients who undergo this procedure require lifelong follow-up and surveillance.", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/30/vascular-surgery-13.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. B) Patients who undergo this procedure require lifelong follow-up and surveillance.</strong></p>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Endovascular aneurysm repair (EVAR) is a suitable option for many infrarenal aneurysms , and patients undergoing this procedure require lifelong follow-up and surveillance to monitor for potential complications . Additionally, EVAR can be considered in the management of ruptured aortic aneurysms.</li><li>➤ Endovascular aneurysm repair</li><li>➤ suitable option for many infrarenal aneurysms</li><li>➤ patients undergoing this procedure require lifelong follow-up and surveillance to monitor</li><li>➤ potential complications</li><li>➤ EVAR</li><li>➤ management of ruptured aortic aneurysms.</li><li>➤ The given image shows an endovascular repair prosthesis . Endovascular aneurysm repair is a procedure done in the surgical management of an aneurysm. The endovascular prosthesis (often termed a ‘ stent graft ’ ) is usually made up of three separate parts : a main body and two limbs that are enclosed in separate delivery catheters . The prosthesis is made from Dacron or PTFE with integral metallic stents for support. The delivery catheter is inserted into the aneurysm sac and the stent–graft deployed by withdrawal of the delivery system. Most systems now have hooks or barbs to anchor the prosthesis in the aortic wall. Currently about 75% of infrarenal aneurysms are suitable for EVAR. Patients who undergo EVAR require lifelong follow-up and surveillance with duplex or CT scans to detect endoleak, disconnection or migration of stent. EVAR should be considered as the first line option for all anatomically suitable ruptured aortic aneurysms.</li><li>➤ The given image shows an endovascular repair prosthesis . Endovascular aneurysm repair is a procedure done in the surgical management of an aneurysm.</li><li>➤ endovascular repair prosthesis</li><li>➤ The endovascular prosthesis (often termed a ‘ stent graft ’ ) is usually made up of three separate parts : a main body and two limbs that are enclosed in separate delivery catheters . The prosthesis is made from Dacron or PTFE with integral metallic stents for support. The delivery catheter is inserted into the aneurysm sac and the stent–graft deployed by withdrawal of the delivery system. Most systems now have hooks or barbs to anchor the prosthesis in the aortic wall.</li><li>➤ endovascular prosthesis</li><li>➤ made up of three separate parts</li><li>➤ main body and two limbs that are enclosed in separate delivery catheters</li><li>➤ Currently about 75% of infrarenal aneurysms are suitable for EVAR.</li><li>➤ Patients who undergo EVAR require lifelong follow-up and surveillance with duplex or CT scans to detect endoleak, disconnection or migration of stent.</li><li>➤ EVAR should be considered as the first line option for all anatomically suitable ruptured aortic aneurysms.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1019.</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1019.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient was presented with severe abdominal pain, hypotension and a pulsatile abdominal mass. Previous investigations had revealed an abdominal aortic aneurysm. With regard to the following condition, identify the incorrect statement:", "options": [{"label": "A", "text": "It is a surgical emergency.", "correct": false}, {"label": "B", "text": "May present with a retroperitoneal hematoma.", "correct": false}, {"label": "C", "text": "Systolic BP must be maintained at &lt;100 mm Hg.", "correct": false}, {"label": "D", "text": "The management of choice is monitoring and resuscitation with surgery reserved only for few cases.", "correct": true}], "correct_answer": "D. The management of choice is monitoring and resuscitation with surgery reserved only for few cases.", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) The management of choice is monitoring and resuscitation with surgery reserved only for few cases.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. It is a surgical emergency: This statement is correct . Ruptured abdominal aortic aneurysm is a surgical emergency, and prompt intervention is crucial to prevent further complications.</li><li>• Option A. It is a surgical emergency:</li><li>• correct</li><li>• Option B. May present with a retroperitoneal hematoma: This statement is correct . Ruptured abdominal aortic aneurysms can present with a retroperitoneal hematoma when the rupture occurs posteriorly into the retroperitoneal space.</li><li>• Option B. May present with a retroperitoneal hematoma:</li><li>• correct</li><li>• Option C. Systolic BP must be maintained at &lt;100 mm Hg: This statement is correct . In the case of a ruptured abdominal aortic aneurysm, the systolic blood pressure should not be raised any more than necessary to maintain consciousness and permit cardiac perfusion, typically kept below 100 mmHg (permissive hypotension).</li><li>• Option C. Systolic BP must be maintained at &lt;100 mm Hg:</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Ruptured abdominal aortic aneurysm is a surgical emergency , and prompt surgical intervention is the management of choice . Maintaining systolic blood pressure below 100 mmHg is crucial , and endovascular aneurysm repair (EVAR) is a preferred option in suitable cases.</li><li>➤ Ruptured abdominal aortic aneurysm</li><li>➤ surgical emergency</li><li>➤ surgical intervention is the management of choice</li><li>➤ Maintaining systolic blood pressure below 100 mmHg</li><li>➤ crucial</li><li>➤ endovascular aneurysm repair</li><li>➤ Abdominal aortic aneurysms can rupture anteriorly into the peritoneal cavity (20%) or posterolaterally into the retroperitoneal space (80%). Anterior rupture results in free bleeding into the peritoneal cavity. Posterior rupture on the other hand produces retroperitoneal hematoma. A ruptured abdominal aortic aneurysm is a surgical emergency. It should be suspected in a patient with the triad of severe abdominal and/or back pain, hypotension, and a pulsatile abdominal mass. If there is doubt about the presence of an aneurysm an ultrasonography scan may help but this cannot diagnose rupture. CT scanning should be used to establish the diagnosis and to confirm a rupture and whether an EVAR is possible . EVAR should be considered as the first-line option for all anatomically suitable ruptured aortic aneurysms. The systolic blood pressure should not be raised any more than is necessary to maintain consciousness and permit cardiac perfusion (&lt;100 mmHg).</li><li>➤ Abdominal aortic aneurysms can rupture anteriorly into the peritoneal cavity (20%) or posterolaterally into the retroperitoneal space (80%). Anterior rupture results in free bleeding into the peritoneal cavity. Posterior rupture on the other hand produces retroperitoneal hematoma.</li><li>➤ A ruptured abdominal aortic aneurysm is a surgical emergency.</li><li>➤ It should be suspected in a patient with the triad of severe abdominal and/or back pain, hypotension, and a pulsatile abdominal mass. If there is doubt about the presence of an aneurysm an ultrasonography scan may help but this cannot diagnose rupture.</li><li>➤ CT scanning should be used to establish the diagnosis and to confirm a rupture and whether an EVAR is possible .</li><li>➤ EVAR should be considered as the first-line option for all anatomically suitable ruptured aortic aneurysms.</li><li>➤ The systolic blood pressure should not be raised any more than is necessary to maintain consciousness and permit cardiac perfusion (&lt;100 mmHg).</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1021</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1021</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of the following are complications of an open aortic aneurysm repair except:", "options": [{"label": "A", "text": "Aortoduodenal fistula", "correct": false}, {"label": "B", "text": "Colonic ischemia", "correct": false}, {"label": "C", "text": "Endoleak", "correct": true}, {"label": "D", "text": "Atelectasis", "correct": false}], "correct_answer": "C. Endoleak", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/13/picture6_lBFE1vU.jpg"], "explanation": "<p><strong>Ans. C) Endoleak</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Aortoduodenal fistula: This is a complication of open aortic aneurysm repair . Aortoduodenal fistula can occur months to years after surgery and presents with symptoms such as hematemesis or melena.</li><li>• Option A. Aortoduodenal fistula:</li><li>• complication of</li><li>• open aortic aneurysm repair</li><li>• Option B. Colonic ischemia: This is a complication of open aortic aneurysm repair . Colonic ischemia can result from impaired blood flow to the colon during the surgical procedure.</li><li>• Option B. Colonic ischemia:</li><li>• complication of open aortic aneurysm repair</li><li>• Option D. Atelectasis: This is a complication of open aortic aneurysm repair . Atelectasis and lung consolidation can occur postoperatively.</li><li>• Option D. Atelectasis:</li><li>• complication of open aortic aneurysm repair</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Complications of open aortic aneurysm repair include aortoduodenal fistula, colonic ischemia, atelectasis, cardiac ischemia, acute kidney injury, sexual dysfunction, spinal cord ischemia , and graft infection . Endoleak is a specific complication of EVAR, not open repair.</li><li>➤ Complications of open aortic aneurysm repair</li><li>➤ aortoduodenal fistula, colonic ischemia, atelectasis, cardiac ischemia, acute kidney injury, sexual dysfunction, spinal cord ischemia</li><li>➤ graft infection</li><li>➤ Complications of open repair-</li><li>➤ Complications of open repair-</li><li>➤ Cardiac ischemia and infarction Atelectasis and lung consolidation Colonic ischemia Acute kidney injury Sexual dysfunction Spinal cord ischemia Aortoduodenal fistula- presents as hematemesis or malena months to years after surgery Graft infection</li><li>➤ Cardiac ischemia and infarction</li><li>➤ Cardiac ischemia and infarction</li><li>➤ Atelectasis and lung consolidation</li><li>➤ Atelectasis and lung consolidation</li><li>➤ Colonic ischemia</li><li>➤ Acute kidney injury</li><li>➤ Sexual dysfunction</li><li>➤ Spinal cord ischemia</li><li>➤ Aortoduodenal fistula- presents as hematemesis or malena months to years after surgery</li><li>➤ Graft infection</li><li>➤ Complications specific to EVAR-</li><li>➤ Complications specific to EVAR-</li><li>➤ Endo-leak which means aneurysm not completely excluded from circulation and may still rupture (see the types below). Graft migration Graft limb occlusion Metal strut fracture</li><li>➤ Endo-leak which means aneurysm not completely excluded from circulation and may still rupture (see the types below).</li><li>➤ Graft migration</li><li>➤ Graft limb occlusion</li><li>➤ Metal strut fracture</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1022.</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1022.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "With regard to popliteal artery aneurysms, all of the following are correct except?", "options": [{"label": "A", "text": "Repair if asymptomatic and size of 10mm", "correct": true}, {"label": "B", "text": "Repair if symptomatic", "correct": false}, {"label": "C", "text": "Imaging of abdominal aorta is indicated", "correct": false}, {"label": "D", "text": "Confirmatory investigation is digital subtraction angiography", "correct": false}], "correct_answer": "A. Repair if asymptomatic and size of 10mm", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Repair if asymptomatic and size of 10mm</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B. Repair if symptomatic: This statement is correct . All symptomatic popliteal aneurysms should be considered for repair.</li><li>• Option B. Repair if symptomatic:</li><li>• correct</li><li>• Option C. Imaging of abdominal aorta is indicated: This statement is correct . Imaging of the abdominal aorta is indicated if a popliteal aneurysm is found because one-third are accompanied by aortic dilatation.</li><li>• Option C. Imaging of abdominal aorta is indicated:</li><li>• correct</li><li>• Option D. Confirmatory investigation is digital subtraction angiography: This statement is correct . While digital subtraction angiography (DSA) can be used for confirmation, the diagnosis is usually confirmed with Duplex ultrasound, and assessment of distal vessels is important prior to repair using CT, MRA, or DSA if foot pulses are diminished or absent.</li><li>• Option D. Confirmatory investigation is digital subtraction angiography:</li><li>• correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Popliteal artery aneurysms should be considered for elective repair if symptomatic or if asymptomatic with a size greater than 20 mm . Examination of the abdominal aorta is indicated if a popliteal aneurysm is found , and the confirmatory investigation includes DSA for assessing distal vessels .</li><li>➤ Popliteal artery aneurysms</li><li>➤ elective repair if symptomatic or if asymptomatic with a size greater than 20 mm</li><li>➤ Examination of the abdominal aorta</li><li>➤ popliteal aneurysm is found</li><li>➤ confirmatory investigation includes DSA for assessing distal vessels</li><li>➤ Popliteal artery aneurysm accounts for 70% of all peripheral aneurysms. It is classically diagnosed in men in their seventh decade of life; 50% are bilateral . Examination of the abdominal aorta is indicated if a popliteal aneurysm is found because one-third are accompanied by aortic dilatation. Popliteal aneurysms present as a swelling behind the knee or with symptoms caused by complications, such as severe ischaemia following thrombosis or distal ischaemia as a result of emboli. The diagnosis is usually confirmed with Duplex USG but assessment of the distal vessels (with CT, MRA or DSA) is important prior to repair if the foot pulses are diminished or absent. An asymptomatic aneurysm greater than 20 mm in diameter should be considered for elective repair to prevent future complications. Some surgeons would also offer elective repair for smaller diameters if the sac contains thrombus because of a perceived increased risk of distal embolisation. All symptomatic popliteal aneurysms should be considered for repair.</li><li>➤ Popliteal artery aneurysm accounts for 70% of all peripheral aneurysms.</li><li>➤ Popliteal artery aneurysm accounts for 70% of all peripheral aneurysms.</li><li>➤ It is classically diagnosed in men in their seventh decade of life; 50% are bilateral .</li><li>➤ men in their seventh decade of life; 50% are bilateral</li><li>➤ Examination of the abdominal aorta is indicated if a popliteal aneurysm is found because one-third are accompanied by aortic dilatation.</li><li>➤ Popliteal aneurysms present as a swelling behind the knee or with symptoms caused by complications, such as severe ischaemia following thrombosis or distal ischaemia as a result of emboli.</li><li>➤ The diagnosis is usually confirmed with Duplex USG but assessment of the distal vessels (with CT, MRA or DSA) is important prior to repair if the foot pulses are diminished or absent.</li><li>➤ An asymptomatic aneurysm greater than 20 mm in diameter should be considered for elective repair to prevent future complications. Some surgeons would also offer elective repair for smaller diameters if the sac contains thrombus because of a perceived increased risk of distal embolisation.</li><li>➤ All symptomatic popliteal aneurysms should be considered for repair.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1023.</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1023.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 30-year-old woman came to the OPD with complaints of her fingers episodically turning white initially and later blue before returning to normal, accompanied by pain in her fingers during these episodes. With regards to the mentioned clinical condition, identify the correct statement:", "options": [{"label": "A", "text": "Raynaud disease is secondary to collagen vascular diseases.", "correct": false}, {"label": "B", "text": "Chances of superficial necrosis and digital amputations are higher in Raynaud syndrome.", "correct": true}, {"label": "C", "text": "Raynaud disease may occur secondary to use of vibrating tools.", "correct": false}, {"label": "D", "text": "Raynaud syndrome is idiopathic and occurs on exposure to cold.", "correct": false}], "correct_answer": "B. Chances of superficial necrosis and digital amputations are higher in Raynaud syndrome.", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/13/screenshot-2023-12-13-154130.jpg"], "explanation": "<p><strong>Ans. B) Chances of superficial necrosis and digital amputations are higher in Raynaud syndrome.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Raynaud disease is secondary to collagen vascular diseases: This statement is incorrect . Raynaud's disease, also known as primary Raynaud's, is idiopathic and not secondary to collagen vascular diseases.</li><li>• Option A. Raynaud disease is secondary to collagen vascular diseases:</li><li>• incorrect</li><li>• primary Raynaud's,</li><li>• idiopathic and not secondary</li><li>• Option C. Raynaud disease may occur secondary to the use of vibrating tools: This statement is incorrect . Raynaud's disease is idiopathic and not associated with external factors like vibrating tools .</li><li>• Option C. Raynaud disease may occur secondary to the use of vibrating tools:</li><li>• incorrect</li><li>• idiopathic and not associated with external factors like vibrating tools</li><li>• Option D. Raynaud syndrome is idiopathic and occurs on exposure to cold: This statement is incorrect . Raynaud's syndrome is not idiopathic; it is secondary to other underlying conditions. Additionally, while exposure to cold can trigger symptoms, it is not the only cause.</li><li>• Option D. Raynaud syndrome is idiopathic and occurs on exposure to cold:</li><li>• incorrect</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Raynaud's disease is idiopathic , primary and not associated with collagen vascular diseases . Raynaud's syndrome is secondary to underlying conditions and carries a higher risk of complications such as superficial necrosis and digital amputations .</li><li>➤ Raynaud's disease is idiopathic</li><li>➤ primary</li><li>➤ not associated with collagen vascular diseases</li><li>➤ Raynaud's syndrome</li><li>➤ secondary to underlying conditions and carries a higher risk of complications</li><li>➤ superficial necrosis and digital amputations</li><li>➤ Raynaud phenomenon is described as a triphasic colour change in the fingers due to vasospasm -</li><li>➤ Raynaud phenomenon</li><li>➤ vasospasm</li><li>➤ White due to arteriolar constriction (stage of syncope) Then blue due to dilatation and filling with de-oxygenated blood (stage of asphyxia) Red, when back to normal (stage of recovery)</li><li>➤ White due to arteriolar constriction (stage of syncope)</li><li>➤ Then blue due to dilatation and filling with de-oxygenated blood (stage of asphyxia)</li><li>➤ Red, when back to normal (stage of recovery)</li><li>➤ It may be due to Raynaud disease or Raynaud syndrome.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1024</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1024</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is not recommended in the treatment of Raynaud syndrome?", "options": [{"label": "A", "text": "Treatment of underlying collagen vascular cause", "correct": false}, {"label": "B", "text": "Nifedipine", "correct": false}, {"label": "C", "text": "Vasospastic antagonists", "correct": false}, {"label": "D", "text": "Sympathectomy", "correct": true}], "correct_answer": "D. Sympathectomy", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/27/untitled-525.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. D) Sympathectomy</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. Treatment of underlying collagen vascular cause: Addressing the underlying collagen vascular cause is crucial in the management of Raynaud's syndrome.</li><li>• Option A. Treatment of underlying collagen vascular cause:</li><li>• Addressing the underlying collagen vascular</li><li>• Option B. Nifedipine : Nifedipine, a calcium channel blocker , is commonly used to dilate blood vessels and improve blood flow , helping alleviate symptoms in Raynaud's syndrome.</li><li>• Option B. Nifedipine</li><li>• calcium channel blocker</li><li>• dilate blood vessels</li><li>• improve blood flow</li><li>• Option C. Vasospastic antagonists : Vasospastic antagonists, which may include medications that dilate blood vessels , can be beneficial in managing the vasospastic episodes characteristic of Raynaud's syndrome.</li><li>• Option C. Vasospastic antagonists</li><li>• medications that dilate blood vessels</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Sympathectomy is not recommended in the treatment of Raynaud's syndrome . Management involves addressing the underlying collagen vascular cause , using medications like nifedipine and vasospastic antagonists , while avoiding triggers like vibrating tools .</li><li>➤ Sympathectomy</li><li>➤ treatment of Raynaud's syndrome</li><li>➤ Management involves addressing the underlying collagen vascular cause</li><li>➤ medications like nifedipine and vasospastic antagonists</li><li>➤ triggers like vibrating tools</li><li>➤ Sympathectomy yields disappointing results and is not recommended. Nifedipine, steroids and vasospastic antagonists may all have a role in treatment. Patients with vibration white finger should avoid vibrating tools.</li><li>➤ Sympathectomy yields disappointing results and is not recommended.</li><li>➤ Nifedipine, steroids and vasospastic antagonists may all have a role in treatment.</li><li>➤ Patients with vibration white finger should avoid vibrating tools.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1024</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1024</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient was diagnosed with thromboangiitis obliterans. Regarding the same, choose the true statements: Also called Buerger disease Can cause superficial thrombophlebitis Affects large arteries like brachial, popliteal Seen in young smokers Raynaud phenomenon seen", "options": [{"label": "A", "text": "1 2 3", "correct": false}, {"label": "B", "text": "1 4 5", "correct": false}, {"label": "C", "text": "1 2 4 5", "correct": true}, {"label": "D", "text": "1 3 4 5", "correct": false}], "correct_answer": "C. 1 2 4 5", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) 1 2 4 5</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Also called Buerger disease : True . Thromboangiitis obliterans is also known as Buerger disease/Smoker’s arteritis. Can cause superficial thrombophlebitis: True . Thromboangiitis obliterans can cause thrombophlebitis of both superficial and deep veins. Affects large arteries like brachial, popliteal : Thromboangiitis obliterans or Buerger disease is an occlusive disease of small and medium-sized limb arteries , typically crural vessels in the lower limb . Seen in young smokers : True . Thromboangiitis obliterans typically occurs in young male smokers. Raynaud phenomenon seen : True . Raynaud's phenomenon is associated with thromboangiitis obliterans.</li><li>• Also called Buerger disease : True . Thromboangiitis obliterans is also known as Buerger disease/Smoker’s arteritis.</li><li>• Also called Buerger disease</li><li>• True</li><li>• Can cause superficial thrombophlebitis: True . Thromboangiitis obliterans can cause thrombophlebitis of both superficial and deep veins.</li><li>• Can cause superficial thrombophlebitis:</li><li>• True</li><li>• Affects large arteries like brachial, popliteal : Thromboangiitis obliterans or Buerger disease is an occlusive disease of small and medium-sized limb arteries , typically crural vessels in the lower limb .</li><li>• Affects large arteries like brachial, popliteal</li><li>• Buerger disease is an occlusive disease of small and medium-sized limb arteries</li><li>• crural vessels in the lower limb</li><li>• Seen in young smokers : True . Thromboangiitis obliterans typically occurs in young male smokers.</li><li>• Seen in young smokers</li><li>• True</li><li>• Raynaud phenomenon seen : True . Raynaud's phenomenon is associated with thromboangiitis obliterans.</li><li>• Raynaud phenomenon seen</li><li>• True</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective</li><li>➤ :</li><li>➤ Thromboangiitis obliterans , also known as Buerger disease , affects small and medium-sized limb arteries , causes thrombophlebitis of superficial or deep veins , is commonly seen in young male smokers , and is associated with Raynaud's phenomenon. Smoking cessation is a crucial aspect of management.</li><li>➤ Thromboangiitis obliterans</li><li>➤ Buerger disease</li><li>➤ small and medium-sized limb arteries</li><li>➤ thrombophlebitis of superficial or deep veins</li><li>➤ young male smokers</li><li>➤ Raynaud's phenomenon.</li><li>➤ Histologically, there are inflammatory changes in the walls of arteries and veins, leading to thrombosis. Treatment is total abstinence from smoking, which arrests, but does not reverse, the disease. Established arterial occlusions are treated as for atheromatous disease, but amputations may eventually be required.</li><li>➤ Histologically, there are inflammatory changes in the walls of arteries and veins, leading to thrombosis.</li><li>➤ Treatment is total abstinence from smoking, which arrests, but does not reverse, the disease. Established arterial occlusions are treated as for atheromatous disease, but amputations may eventually be required.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1024</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1024</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Corkscrew collaterals are radiologically seen in:", "options": [{"label": "A", "text": "Aortoiliac obstruction", "correct": false}, {"label": "B", "text": "Buerger disease", "correct": true}, {"label": "C", "text": "Raynaud disease", "correct": false}, {"label": "D", "text": "Varicose veins", "correct": false}], "correct_answer": "B. Buerger disease", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/13/picture9_RHwXw0W.jpg"], "explanation": "<p><strong>Ans. B) Buerger disease</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Corkscrew collaterals are radiologically seen in Buerger disease .</li><li>• Corkscrew collaterals are radiologically seen in Buerger disease</li><li>• Thromboangiitis obliterans or Buerger disease is an occlusive disease of small and medium-sized limb arteries , t hrombophlebitis of superficial or deep veins and Raynaud ’ s syndrome .</li><li>• Thromboangiitis obliterans</li><li>• occlusive disease of small and</li><li>• medium-sized limb arteries</li><li>• hrombophlebitis</li><li>• superficial or deep veins and Raynaud</li><li>• s syndrome</li><li>• Histologically, there are inflammatory changes in the walls of arteries and veins , leading to thrombosis . Corkscrew collaterals are typically seen on angiogram.</li><li>• inflammatory changes in the walls of arteries and veins</li><li>• thrombosis</li><li>• Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1024</li><li>• Ref: Bailey and Love’s Short Practice of Surgery 28th Edition Page 1024</li><li>• https://radiopaedia.org/articles/buerger-disease</li><li>• https://radiopaedia.org/articles/buerger-disease</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "With regard to thoracic aortic aneurysms, choose the incorrect statement:", "options": [{"label": "A", "text": "In patients of Marfan’s syndrome, an ascending aneurysm of 4.5-5 cm must be operated.", "correct": false}, {"label": "B", "text": "Progressive aortic valve insufficiency is an indication for surgery.", "correct": false}, {"label": "C", "text": "Asymptomatic descending aneurysm of size 5.5 cm requires surgery.", "correct": true}, {"label": "D", "text": "Most common cause of thoracic aortic aneurysm is atherosclerosis.", "correct": false}], "correct_answer": "C. Asymptomatic descending aneurysm of size 5.5 cm requires surgery.", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Asymptomatic descending aneurysm of size 5.5 cm requires surgery.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A. In patients with Marfan’s syndrome, an ascending aneurysm of 4.5-5 cm must be operated. Correct . Individuals with Marfan's syndrome are at a higher risk of aortic complications, and surgery is generally recommended for ascending aortic aneurysms at a size of 4.5-5 cm to prevent rupture.</li><li>• Option A. In patients with Marfan’s syndrome, an ascending aneurysm of 4.5-5</li><li>• cm</li><li>• Correct</li><li>• Option B. Progressive aortic valve insufficiency is an indication for surgery. Correct . Aortic valve insufficiency (regurgitation) can be a complication of thoracic aortic aneurysms, especially when involving the ascending aorta. If there is progression of aortic valve insufficiency, surgery may be indicated.</li><li>• Option B. Progressive aortic valve insufficiency is an indication for surgery. Correct</li><li>• Option D. Most common cause of thoracic aortic aneurysm is atherosclerosis . Correct . The most common etiology of thoracic aortic aneurysm is atherosclerosis. Other causes include Marfan’s syndrome, Ehler Danlos syndrome, connective tissue disorders.</li><li>• Option D. Most common cause of thoracic aortic aneurysm is atherosclerosis</li><li>• Correct</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• In thoracic aortic aneurysms, indications for surgery are -</li><li>• thoracic aortic aneurysms, indications for surgery are</li><li>• Symptomatic</li><li>• Symptomatic</li><li>• When asymptomatic-</li><li>• Ascending aneurysm- Marfan syndrome related, size 4.5-5.0 cm, progressive aortic valve insufficiency. Descending aneurysm- 6 cm</li><li>• Ascending aneurysm- Marfan syndrome related, size 4.5-5.0 cm, progressive aortic valve insufficiency.</li><li>• Descending aneurysm- 6 cm</li><li>• The most common etiology of thoracic aortic aneurysm is atherosclerosis. Other causes include Marfan’s syndrome, Ehler Danlos syndrome, connective tissue disorders.</li><li>• common etiology of thoracic aortic aneurysm is atherosclerosis.</li><li>• Many aneurysms are asymptomatic and are discovered incidentally on routine chest radiographs. Others present as a space-occupying lesion in the thorax with-</li><li>• aneurysms are asymptomatic</li><li>• incidentally on routine chest radiographs.</li><li>• Pain caused by pressure on adjacent structures (vertebra), Hoarseness (left recurrent laryngeal nerve), Dysphagia (oesophagus) and R espi ratory symptoms (left main bronchus).</li><li>• Pain caused by pressure on adjacent structures (vertebra),</li><li>• Hoarseness (left recurrent laryngeal nerve),</li><li>• Dysphagia (oesophagus) and</li><li>• R espi ratory symptoms (left main bronchus).</li><li>• Aortic root aneurysms may lead to dilatation of the aortic root annulus and aortic regurgitation .</li><li>• Aortic root aneurysms</li><li>• dilatation of the aortic root annulus</li><li>• aortic regurgitation</li><li>• Rupture can lead to cardiac tamponade or haemorrhage into the left pleural space , leading to dyspnoea and, if the tracheobronchial airway or oesophagus is involved, haemoptysis or haematemesis.</li><li>• Rupture can lead to cardiac tamponade</li><li>• haemorrhage into the left pleural space</li><li>• dyspnoea</li><li>• Diagnosis- CT angiogram thorax</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 970</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Page 970</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A resident was trying to examine for thoracic outlet syndrome in a patient. Identify the test being performed:", "options": [{"label": "A", "text": "Roos test", "correct": true}, {"label": "B", "text": "Halsted test", "correct": false}, {"label": "C", "text": "Wright test", "correct": false}, {"label": "D", "text": "Adson test", "correct": false}], "correct_answer": "A. Roos test", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/27/untitled-527.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/30/vascular-surgery-15.jpeg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/30/arterial-disorders-4.jpg"], "explanation": "<p><strong>Ans. A) Roos test</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Thoracic outlet syndrome (TOS) refers to compression of the subclavian vessels and nerves of the brachial plexus in the region of the thoracic outlet .</li><li>• Thoracic outlet syndrome</li><li>• compression of the subclavian vessels</li><li>• nerves of the brachial plexus</li><li>• region of the thoracic outlet</li><li>• Middle-aged women are most commonly affected . The subclavian vessels and the brachial plexus can be compressed at various locations as they pass between the thoracic inlet and the upper extremity .</li><li>• Middle-aged women</li><li>• commonly affected</li><li>• subclavian vessels</li><li>• brachial plexus</li><li>• compressed at various locations</li><li>• pass between the thoracic inlet</li><li>• upper extremity</li><li>• Provocative tests include the following :</li><li>• Provocative tests include the following</li><li>• Adson (scalene) test . The patient inspires maximally and holds his or her breath while the neck is fully extended and the head is turned toward the affected side. Decrease or loss of ipsilateral radial pulse suggests compression. In reverse Adson’s test, head is turned towards normal side. Halsted (costoclavicular) test . The patient is instructed to place his or her shoulders in a military position (drawn backward and downward) to narrow the costoclavicular space between the first rib and the clavicle, causing neurovascular compression. Reproduction of neurologic symptoms or decrease or loss of ipsilateral radial pulse suggests compression. Wright (hyperabduction) test . The patient ’ s arm is hyperabducted to 180 degrees. Decrease or loss of ipsilateral radial pulse suggests compression. Roos test . The patient abducts the involved arm 90 degrees with external rotation of the shoulder. Maintaining this body position, the modified Roos test is performed by opening and closing the hand rapidly for 3 minutes in an attempt to reproduce symptoms. Allen’s test: Alternate compression of radial and ulnar artery to check perfusion of palm (done prior to ABG collection)</li><li>• Adson (scalene) test . The patient inspires maximally and holds his or her breath while the neck is fully extended and the head is turned toward the affected side. Decrease or loss of ipsilateral radial pulse suggests compression. In reverse Adson’s test, head is turned towards normal side.</li><li>• Adson</li><li>• test</li><li>• Halsted (costoclavicular) test . The patient is instructed to place his or her shoulders in a military position (drawn backward and downward) to narrow the costoclavicular space between the first rib and the clavicle, causing neurovascular compression. Reproduction of neurologic symptoms or decrease or loss of ipsilateral radial pulse suggests compression.</li><li>• Halsted</li><li>• test</li><li>• Wright (hyperabduction) test . The patient ’ s arm is hyperabducted to 180 degrees. Decrease or loss of ipsilateral radial pulse suggests compression.</li><li>• Wright</li><li>• test</li><li>• Roos test . The patient abducts the involved arm 90 degrees with external rotation of the shoulder. Maintaining this body position, the modified Roos test is performed by opening and closing the hand rapidly for 3 minutes in an attempt to reproduce symptoms.</li><li>• Roos test</li><li>• Allen’s test: Alternate compression of radial and ulnar artery to check perfusion of palm (done prior to ABG collection)</li><li>• Allen’s test: Alternate compression of radial and ulnar artery to check perfusion of palm (done prior to ABG collection)</li><li>• Boundaries of thoracic outlet/scalene triangle: Scalene anterior, scalene medius and 1 st rib. Compression/thoracic outlet syndrome usually occurs due to cervical rib and affects subclavian vessels or brachial plexus exiting this space.</li><li>• Boundaries of thoracic outlet/scalene triangle: Scalene anterior, scalene medius and 1 st rib. Compression/thoracic outlet syndrome usually occurs due to cervical rib and affects subclavian vessels or brachial plexus exiting this space.</li><li>• Symptoms of subclavian artery compression include fatigue, weakness, coldness, upper extremity claudication, thrombosis, and paresthesia. Thrombosis with distal embolization rarely can occur, producing vasomotor symptoms (Raynaud phenomenon) in the hand or ischemic changes.</li><li>• Venous compression results in edema, venous distention, collateral formation, and cyanosis of the affected limb.</li><li>• Neurogenic thoracic outlet syndrome presents due to compression of the brachial plexus. Vague pain is a common symptom. Atrophy of the intrinsic muscles of the hand can also occur, as well as weakness in the hand and neurologic sensory deficits. They are more common than vascular symptoms.</li><li>• Neurogenic thoracic outlet syndrome presents due to compression of the brachial plexus. Vague pain is a common symptom. Atrophy of the intrinsic muscles of the hand can also occur, as well as weakness in the hand and neurologic sensory deficits. They are more common than vascular symptoms.</li><li>• Ref : Sabiston Textbook of Surgery 20th Edition Page 1604.</li><li>• Ref</li><li>• : Sabiston Textbook of Surgery 20th Edition Page 1604.</li><li>• https://www.ncbi.nlm.nih.gov/books/NBK557450/</li><li>• https://www.ncbi.nlm.nih.gov/books/NBK557450/</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is incorrect about thoracic outlet syndrome?", "options": [{"label": "A", "text": "Arterial syndrome typically occludes subclavian artery", "correct": false}, {"label": "B", "text": "Neurogenic compression of upper trunk of brachial plexus is common", "correct": true}, {"label": "C", "text": "Fibrous band arising from cervical rib causes compression commonly", "correct": false}, {"label": "D", "text": "Wasting of intrinsic muscles of hand is seen", "correct": false}], "correct_answer": "B. Neurogenic compression of upper trunk of brachial plexus is common", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Neurogenic compression of upper trunk of brachial plexus is common</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Arterial syndrome typically occludes subclavian artery : In thoracic outlet syndrome , arterial compression typically affects the subclavian artery . Therefore, statement A is correct.</li><li>• Option A:</li><li>• Arterial syndrome</li><li>• typically occludes subclavian artery</li><li>• thoracic outlet syndrome</li><li>• arterial compression</li><li>• subclavian artery</li><li>• Option C. A fibrous band arising from a cervical rib can cause compression commonly in thoracic outlet syndrome . This is correct, cervical rib is the most common cause.</li><li>• Option</li><li>• C. A fibrous band arising from a cervical rib</li><li>• cause compression</li><li>• thoracic outlet syndrome</li><li>• Option D. Wasting of intrinsic muscles of the hand is seen in thoracic outlet syndrome , particularly in cases where neurogenic compression affects the brachial plexus , leading to weakness and atrophy of the muscles supplied by the affected nerves.</li><li>• Option</li><li>• D. Wasting of intrinsic muscles</li><li>• thoracic outlet syndrome</li><li>• neurogenic compression affects the brachial plexus</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Cervical rib and thoracic outlet syndrome</li><li>• Cervical rib and thoracic outlet syndrome</li><li>• This rib is usually represented by a fibrous band originating from the seventh cervical vertebra and inserting onto the first thoracic rib. It may be asymptomatic , but because the subclavian artery and brachial plexus course over it a variety of symptoms may occur. The lower trunk of the plexus (mainly T1) is compressed, leading to wasting of the interossei and altered sensation in the T1 distribution. Compression of the subclavian artery may result in a post-stenotic dilatation with thrombus and embolus formation. The diagnosis, assessment and surgery are fraught with uncertainties, a neck X ray may show the cervical rib. MRI neck will confirm the diagnosis. Treatment involves excision of the rib.</li><li>• This rib is usually represented by a fibrous band originating from the seventh cervical vertebra and inserting onto the first thoracic rib.</li><li>• represented by a fibrous band originating from the seventh cervical vertebra</li><li>• It may be asymptomatic , but because the subclavian artery and brachial plexus course over it a variety of symptoms may occur.</li><li>• asymptomatic</li><li>• The lower trunk of the plexus (mainly T1) is compressed, leading to wasting of the interossei and altered sensation in the T1 distribution.</li><li>• lower trunk of the plexus</li><li>• Compression of the subclavian artery may result in a post-stenotic dilatation with thrombus and embolus formation.</li><li>• Compression of the subclavian artery</li><li>• The diagnosis, assessment and surgery are fraught with uncertainties, a neck X ray may show the cervical rib. MRI neck will confirm the diagnosis. Treatment involves excision of the rib.</li><li>• Ref : Bailey and Love 28 th Edition, Pg 995.</li><li>• Ref</li><li>• : Bailey and Love 28 th Edition, Pg 995.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Regarding the venous anatomy of the lower limb, find the correct statement:", "options": [{"label": "A", "text": "The Great Saphenous Vein is accompanied by sural nerve along it's course.", "correct": false}, {"label": "B", "text": "The location of sapheno-popliteal junction, into which the Short Saphenous vein empties, is highly variable.", "correct": true}, {"label": "C", "text": "The Vein of Giacomini is the cranial extension of the Great Saphenous Vein.", "correct": false}, {"label": "D", "text": "Perforators allow blood flow from deep to superficial venous system.", "correct": false}], "correct_answer": "B. The location of sapheno-popliteal junction, into which the Short Saphenous vein empties, is highly variable.", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/30/vascular-surgery-16.jpg"], "explanation": "<p><strong>Ans. B) The location of saphenopopliteal junction, into which the Short Saphenous vein empties, is highly variable.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• :</li><li>• Option A. The Great Saphenous Vein is accompanied by sural nerve along its course. This statement is incorrect . The Great Saphenous Vein (GSV) is typically accompanied by the saphenous nerve , not the sural nerve. The sural nerve runs with the Small Saphenous Vein (SSV).</li><li>• Option A. The Great Saphenous Vein is accompanied by sural nerve along its course.</li><li>• incorrect</li><li>• Great Saphenous Vein</li><li>• accompanied by the saphenous nerve</li><li>• Option C. The Vein of Giacomini is the cranial extension of the Great Saphenous Vein.</li><li>• Option C. The Vein of Giacomini is the cranial extension of the Great Saphenous Vein.</li><li>• This statement is incorrect . The Vein of Giacomini is actually an extension of the Small Saphenous Vein (SSV), not the Great Saphenous Vein (GSV).</li><li>• incorrect</li><li>• Vein of Giacomini is actually an extension of the Small Saphenous Vein</li><li>• Option D. Perforators allow blood flow from deep to superficial venous system. This statement is incorrect . Perforating veins, also known as communicating veins , primarily allow blood to flow from the superficial venous system to the deep venous system .</li><li>• Option D. Perforators allow blood flow from deep to superficial venous system.</li><li>• incorrect</li><li>• communicating veins</li><li>• allow blood to flow from the superficial venous system to the deep venous system</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Anatomy of superficial veins of lower limb</li><li>➤ Anatomy of superficial veins of lower limb</li><li>➤ The majority of the venous drainage of the foot is into the dorsal venous arch, running in the subcutaneous tissues over the metatarsal heads. The medial end of this arch drains into the great saphenous vein (GSV). This is the longest vein in the body and is the most frequently affected by superficial incompetence. The GSV passes anterior to the medial malleolus and ascends the leg accompanied by the saphenous nerve in the superficial tissues medial to the tibia , looping posteriorly at the level of the medial condyle of the femur and continuing in the medial thigh. In the groin, it unites with tributaries corresponding to the arterial branches of the common femoral artery, before piercing the cribriform fascia covering the saphenous opening (approximately 2.5 cm below and lateral to the pubic tubercle, but often somewhat higher) and terminates by draining into the common femoral vein (CFV) at the saphenofemoral junction (SFJ). The small saphenous vein (SSV) originates from the lateral side of the dorsal venous arch and accompanies the sural nerve as it passes posterior to the lateral malleolus, then upwards in the posterior midline of the leg. In the proximal calf it is usually found sitting in the groove between the two muscular heads of gastrocnemius. Its termination commonly occurs by piercing the fascia of the popliteal fossa to drain into the popliteal vein at the saphenopopliteal junction (SPJ). However, this junction is highly variable. The Vein of Giacomini is the cranial extension of Short Saphenous Vein, found in some people. In the calf and thigh there are a number of valved perforating (communicating) veins which allow blood to flow from the superficial to the deep venous system.</li><li>➤ The majority of the venous drainage of the foot is into the dorsal venous arch, running in the subcutaneous tissues over the metatarsal heads. The medial end of this arch drains into the great saphenous vein (GSV). This is the longest vein in the body and is the most frequently affected by superficial incompetence.</li><li>➤ This is the longest vein in the body and is the most frequently affected by superficial incompetence.</li><li>➤ The GSV passes anterior to the medial malleolus and ascends the leg accompanied by the saphenous nerve in the superficial tissues medial to the tibia , looping posteriorly at the level of the medial condyle of the femur and continuing in the medial thigh.</li><li>➤ GSV passes anterior to the medial malleolus</li><li>➤ ascends the leg</li><li>➤ saphenous nerve</li><li>➤ superficial tissues medial to the tibia</li><li>➤ In the groin, it unites with tributaries corresponding to the arterial branches of the common femoral artery, before piercing the cribriform fascia covering the saphenous opening (approximately 2.5 cm below and lateral to the pubic tubercle, but often somewhat higher) and terminates by draining into the common femoral vein (CFV) at the saphenofemoral junction (SFJ).</li><li>➤ The small saphenous vein (SSV) originates from the lateral side of the dorsal venous arch and accompanies the sural nerve as it passes posterior to the lateral malleolus, then upwards in the posterior midline of the leg. In the proximal calf it is usually found sitting in the groove between the two muscular heads of gastrocnemius. Its termination commonly occurs by piercing the fascia of the popliteal fossa to drain into the popliteal vein at the saphenopopliteal junction (SPJ). However, this junction is highly variable.</li><li>➤ The Vein of Giacomini is the cranial extension of Short Saphenous Vein, found in some people.</li><li>➤ In the calf and thigh there are a number of valved perforating (communicating) veins which allow blood to flow from the superficial to the deep venous system.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1025-1026</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1025-1026</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of the following are risk factors for developing varicose veins except:", "options": [{"label": "A", "text": "Obesity", "correct": false}, {"label": "B", "text": "Family history", "correct": false}, {"label": "C", "text": "Multiple pregnancies", "correct": false}, {"label": "D", "text": "Smoking", "correct": true}], "correct_answer": "D. Smoking", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Smoking</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Obesity. Obesity is a well-established risk factor for varicose veins . The increased body weight in obese individuals puts extra pressure on the veins, particularly in the legs, which can lead to venous insufficiency and varicose veins.</li><li>• Option A: Obesity.</li><li>• well-established risk factor for varicose veins</li><li>• Option B: Family history. A family history of varicose veins suggests a genetic predisposition to this condition .</li><li>• Option B: Family history.</li><li>• genetic predisposition to this condition</li><li>• Option C: Multiple pregnancies. Multiple pregnancies are a risk factor for varicose veins due to the increased volume of blood and hormonal changes that can lead to venous dilation and valve dysfunction, as well as the physical pressure of the enlarging uterus on the veins.</li><li>• Option C: Multiple pregnancies.</li><li>• risk factor for varicose veins due to the increased volume of blood and hormonal changes</li><li>• venous dilation</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ While obesity, family history, and multiple pregnancies are established risk factors for varicose veins , the evidence linking smoking to varicose veins is not conclusive , highlighting the complexity of vascular disease etiology.</li><li>➤ obesity, family history, and multiple pregnancies</li><li>➤ risk factors for varicose veins</li><li>➤ linking smoking to varicose veins is not conclusive</li><li>➤ Risk factors for varicose veins include –</li><li>➤ Risk factors for varicose veins include</li><li>➤ Gender – females more than males Age – prevalence increases with age Ethnicity Body mass index and height – risk increases with increase in both Pregnancy – increases the risk of varicose veins Family history</li><li>➤ Gender – females more than males</li><li>➤ Age – prevalence increases with age</li><li>➤ Ethnicity</li><li>➤ Body mass index and height – risk increases with increase in both</li><li>➤ Pregnancy – increases the risk of varicose veins</li><li>➤ Family history</li><li>➤ Primary varicose veins occur due to developmental defects in the Vein wall which causes loss of compliance , dilatation and valvular incompetence.</li><li>➤ Primary varicose veins</li><li>➤ developmental defects in the Vein wall</li><li>➤ loss of compliance</li><li>➤ Secondary varicose veins developed in patients with post – thrombotic limb, pregnancy, pelvic tumours and in patients of multiple arteriovenous fistulae and Klippel Trenaunay syndrome .</li><li>➤ Secondary varicose veins</li><li>➤ patients with post – thrombotic limb, pregnancy, pelvic tumours</li><li>➤ multiple arteriovenous fistulae and Klippel Trenaunay syndrome</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1030</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1030</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient came with complaints of pain in right calf for six months. The pain was mild, dull aching, worsened on prolonged standing and was relieved on rest. She also complained of multiple swellings on medial aspect of the right lower limb which had started initially in the foot and later progressed upwards till the calf. What is the mostly likely etiology?", "options": [{"label": "A", "text": "Deep vein thrombosis", "correct": false}, {"label": "B", "text": "Varicose veins", "correct": true}, {"label": "C", "text": "Peripheral arterial disease", "correct": false}, {"label": "D", "text": "Neurogenic claudication", "correct": false}], "correct_answer": "B. Varicose veins", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Varicose veins</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option A: Deep vein thrombosis (DVT). DVT is characterized by acute and severe pain and swelling in one leg , usually associated with warmth and redness . The pain in DVT tends to be more acute and severe than described in the scenario.</li><li>• Option A: Deep vein thrombosis (DVT).</li><li>• DVT</li><li>• acute and severe pain and swelling in one leg</li><li>• warmth and redness</li><li>• Option C: Peripheral arterial disease (PAD). PAD typically presents with claudication, which is muscle pain on exertion that resolves with rest , and is due to arterial insufficiency. The pain is often described as crampy or fatiguing and occurs with predictable levels of exercise.</li><li>• Option C: Peripheral arterial disease (PAD).</li><li>• PAD</li><li>• presents with claudication, which is muscle pain on exertion that resolves with rest</li><li>• due to arterial insufficiency.</li><li>• Option D: Neurogenic claudication. Neurogenic claudication results from compression of the spinal nerves , often due to lumbar spinal stenosis . It causes pain in the lower back and legs that is worsened by standing and walking and relieved by bending forward or sitting down. Unlike varicose veins, it is not associated with visible swelling of the veins.</li><li>• Option D: Neurogenic claudication.</li><li>• compression of the spinal nerves</li><li>• lumbar spinal stenosis</li><li>• pain in the lower back and legs that is worsened by standing and walking</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ In this case, varicose veins are most consistent with the patient's presentation .</li><li>➤ varicose veins</li><li>➤ most consistent with the patient's presentation</li><li>➤ Symptoms - include dull aching pain especially in the calf that increases throughout the day or with prolonged standing and is relieved by elevation or compression stockings.</li><li>➤ Symptoms</li><li>➤ Signs -</li><li>➤ Signs</li><li>➤ Varicose vein : subcutaneous dilated vein 3 mm in diameter or larger. They are frequently elongated and tortuous, with intermittent ‘ blowouts ’ , but are defined by the presence of reflux. Telangiectasia (thread veins, spider veins and hyphen webs): represent tiny intradermal venules less than 1 mm in diameter . Reticular vein : small dilated ‘ bluish ’ subdermal vein 1–2.9 mm in diameter . Saphena varix : is a (usually painless) groin swelling apparent on standing. Corona phlebectatica (malleolar flare): a fan-shaped pattern of telangiectasia on the ankle or foot. This is an early sign of advanced venous disease. Oedema : increased volume of fluid in the skin and soft tissues of the leg. Commonly starts distally and moves more proximally with increasing venous dysfunction. Classically this is ‘ pitting oedema ’ , with firm digital pressure leaving an indentation in the soft tissues. Eczema : an erythematous dermatitis, often appears minor, although it may be associated with significant itching and discomfort. Pigmentation (haemosiderosis): a brownish discoloration of the skin, usually permanent. It is usually seen around the ankle, but is also seen in proximity to varicose veins and incompetent perforators. Lipodermatosclerosis (LDS): chronic inflammation and fibrosis of the skin and subcutaneous tissues, resulting in a tight, contracted, ‘ woody ’ leg on examination. Atrophie blanche : localised areas of atrophic, white skin, often surrounded by telangiectasia and pigmentation. Venous ulcer : full-thickness skin loss, usually around the ankle, which fails to heal spontaneously and is propagated by continuing venous hypertension and the changes associated with chronic venous disease.</li><li>➤ Varicose vein : subcutaneous dilated vein 3 mm in diameter or larger. They are frequently elongated and tortuous, with intermittent ‘ blowouts ’ , but are defined by the presence of reflux.</li><li>➤ Varicose vein</li><li>➤ Telangiectasia (thread veins, spider veins and hyphen webs): represent tiny intradermal venules less than 1 mm in diameter .</li><li>➤ Telangiectasia</li><li>➤ Reticular vein : small dilated ‘ bluish ’ subdermal vein 1–2.9 mm in diameter .</li><li>➤ Reticular vein</li><li>➤ Saphena varix : is a (usually painless) groin swelling apparent on standing.</li><li>➤ Saphena varix</li><li>➤ Corona phlebectatica (malleolar flare): a fan-shaped pattern of telangiectasia on the ankle or foot. This is an early sign of advanced venous disease.</li><li>➤ Corona phlebectatica</li><li>➤ Oedema : increased volume of fluid in the skin and soft tissues of the leg. Commonly starts distally and moves more proximally with increasing venous dysfunction. Classically this is ‘ pitting oedema ’ , with firm digital pressure leaving an indentation in the soft tissues.</li><li>➤ Oedema</li><li>➤ Eczema : an erythematous dermatitis, often appears minor, although it may be associated with significant itching and discomfort.</li><li>➤ Eczema</li><li>➤ Pigmentation (haemosiderosis): a brownish discoloration of the skin, usually permanent. It is usually seen around the ankle, but is also seen in proximity to varicose veins and incompetent perforators.</li><li>➤ Pigmentation</li><li>➤ Lipodermatosclerosis (LDS): chronic inflammation and fibrosis of the skin and subcutaneous tissues, resulting in a tight, contracted, ‘ woody ’ leg on examination.</li><li>➤ Lipodermatosclerosis</li><li>➤ Atrophie blanche : localised areas of atrophic, white skin, often surrounded by telangiectasia and pigmentation.</li><li>➤ Atrophie blanche</li><li>➤ Venous ulcer : full-thickness skin loss, usually around the ankle, which fails to heal spontaneously and is propagated by continuing venous hypertension and the changes associated with chronic venous disease.</li><li>➤ Venous ulcer</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1028</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1028</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient came to the surgery OPD with dilated, tortuous veins, around 4 mm in diameter with dull aching discomfort. Classify this according to the CEAP classification?", "options": [{"label": "A", "text": "C1a", "correct": false}, {"label": "B", "text": "C2a", "correct": false}, {"label": "C", "text": "C1a", "correct": false}, {"label": "D", "text": "C2s", "correct": true}], "correct_answer": "D. C2s", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) C2s</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Symptomatic varicose veins &gt; 3 mm are categorized as C2s.</li><li>• Symptomatic varicose veins &gt; 3 mm</li><li>• C2s.</li><li>• The descriptive CEAP (Clinical–Etiology– Anatomy –Pathophysiology) classification for chronic venous disorders is widely utilised.</li><li>• CEAP (Clinical–Etiology–</li><li>• Anatomy</li><li>• –Pathophysiology) classification</li><li>• For clinical classification:</li><li>• For clinical classification:</li><li>• C0 : No signs of venous disease; C1 : Telangiectasia or Reticular veins (&lt; 3mm); C2 : Varicose veins ( &gt;3 mm); C3 : Oedema; C4a : Pigmentation or eczema; C4b : Lipodermatosclerosis or Atrophie blanche; C4c Corona phlebectatica C5 : Healed venous ulcer; C6 : Active venous ulcer.</li><li>• C0 : No signs of venous disease;</li><li>• C0</li><li>• C1 : Telangiectasia or Reticular veins (&lt; 3mm);</li><li>• C1</li><li>• C2 : Varicose veins ( &gt;3 mm);</li><li>• C2</li><li>• C3 : Oedema;</li><li>• C3</li><li>• C4a : Pigmentation or eczema;</li><li>• C4a</li><li>• C4b : Lipodermatosclerosis or Atrophie blanche;</li><li>• C4b</li><li>• C4c Corona phlebectatica</li><li>• C4c</li><li>• C5 : Healed venous ulcer;</li><li>• C5</li><li>• C6 : Active venous ulcer.</li><li>• C6</li><li>• Clinical class can be further characterised as symptomatic (s), asymptomatic (a) or recurrent (r) following previous successful treatment or healing (r), e.g., C2a, C2s, C6r.</li><li>• Clinical class</li><li>• symptomatic</li><li>• asymptomatic</li><li>• recurrent</li><li>• For etiological classification:</li><li>• For etiological classification:</li><li>• Ec: Congenital; Ep: Primary; Es: Secondary (post-thrombotic); En: No venous cause identified.</li><li>• Ec: Congenital;</li><li>• Ep: Primary;</li><li>• Es: Secondary (post-thrombotic); En: No venous cause identified.</li><li>• En: No venous cause identified.</li><li>• En: No venous cause identified.</li><li>• For anatomical classification:</li><li>• For anatomical classification:</li><li>• As: Superficial veins; Ap: Perforator veins; Ad: Deep veins; An: No venous location identified.</li><li>• As: Superficial veins;</li><li>• Ap: Perforator veins;</li><li>• Ad: Deep veins;</li><li>• An: No venous location identified.</li><li>• For pathophysiological classification:</li><li>• For pathophysiological classification:</li><li>• Pr: Reflux. Po : Obstruction; Pr,o: Reflux and obstruction; Pn: No venous pathophysiology identifiable.</li><li>• Pr: Reflux.</li><li>• Po : Obstruction;</li><li>• Pr,o: Reflux and obstruction;</li><li>• Pn: No venous pathophysiology identifiable.</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1030</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1030</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Grade the following finding in a patient with varicose veins, with limb swelling and feeling of limb thickening on palpation, according to the CEAP classification?", "options": [{"label": "A", "text": "C2", "correct": false}, {"label": "B", "text": "C3", "correct": false}, {"label": "C", "text": "C4a", "correct": false}, {"label": "D", "text": "C4b", "correct": true}], "correct_answer": "D. C4b", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/27/untitled-545.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. D) C4b</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• The image and clinical finding (limb thickening) shows lipodermatosclerosis with inverted champagne bottle leg , which is C4b of the CEAP classification .</li><li>• lipodermatosclerosis</li><li>• inverted champagne bottle leg</li><li>• C4b of the CEAP classification</li><li>• For clinical classification:</li><li>• C0 : no signs of venous disease; C1 : telangiectasia or reticular veins; C2 : varicose veins; C3 : oedema; C4a : pigmentation or eczema; C4b : Lipodermatosclerosis or atrophie blanche; C4c : Corona phlebectatica C5 : healed venous ulcer; C6 : active venous ulcer.</li><li>• C0 : no signs of venous disease;</li><li>• C0</li><li>• C1 : telangiectasia or reticular veins;</li><li>• C1</li><li>• C2 : varicose veins;</li><li>• C2</li><li>• C3 : oedema;</li><li>• C3</li><li>• C4a : pigmentation or eczema;</li><li>• C4a</li><li>• C4b : Lipodermatosclerosis or atrophie blanche;</li><li>• C4b</li><li>• C4c : Corona phlebectatica</li><li>• C4c</li><li>• C5 : healed venous ulcer;</li><li>• C5</li><li>• C6 : active venous ulcer.</li><li>• C6</li><li>• Clinical class can be further characterised as symptomatic (s), asymptomatic (a) or recurrent following previous successful treatment or healing (r), e.g. C2a, C2s, C6r.</li><li>• symptomatic</li><li>• asymptomatic</li><li>• recurrent</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1030</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1030</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "3 patients, A, B and C, of varicose veins in a surgery OPD had findings of edema, eczema and atrophie blanchie respectively. Classify them according to CEAP classification?", "options": [{"label": "A", "text": "A- C2, B- C3, C- C4a", "correct": false}, {"label": "B", "text": "A- C3, B- C4a, C- C4b", "correct": true}, {"label": "C", "text": "A- C2, B- C3, C- C4b", "correct": false}, {"label": "D", "text": "A- C3, B- C4b, C- C4c", "correct": false}], "correct_answer": "B. A- C3, B- C4a, C- C4b", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) A- C3, B- C4a, C- C4b</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• For clinical classification:</li><li>• C0: no signs of venous disease; C1: telangiectasia or reticular veins; C2: varicose veins; C3: oedema; C4a: pigmentation or eczema; C4b: Lipodermatosclerosis or atrophie blanche; C4c: Corona phlebectatica C5: healed venous ulcer; C6: active venous ulcer.</li><li>• C0: no signs of venous disease;</li><li>• C1: telangiectasia or reticular veins;</li><li>• C2: varicose veins;</li><li>• C3: oedema;</li><li>• C4a: pigmentation or eczema;</li><li>• C4b: Lipodermatosclerosis or atrophie blanche;</li><li>• C4c: Corona phlebectatica</li><li>• C5: healed venous ulcer;</li><li>• C6: active venous ulcer.</li><li>• Clinical class can be further characterised as symptomatic (s), asymptomatic (a) or recurrent following previous successful treatment or healing (r), e.g. C2a, C2s, C6r.</li><li>• For aetiological classification: Ec: congenital; Ep: primary; Es: secondary (post-thrombotic); En: no venous cause identified.</li><li>• For aetiological classification:</li><li>• Ec: congenital;</li><li>• Ep: primary;</li><li>• Es: secondary (post-thrombotic);</li><li>• En: no venous cause identified.</li><li>• For anatomical classification:</li><li>• As: superficial veins; Ap: perforator veins; Ad: deep veins; An: no venous location identified.</li><li>• As: superficial veins;</li><li>• Ap: perforator veins;</li><li>• Ad: deep veins;</li><li>• An: no venous location identified.</li><li>• For pathophysiological classification:</li><li>• Pr: reflux; Po: obstruction; Pr,o: reflux and obstruction; Pn: no venous pathophysiology identifiable.</li><li>• Pr: reflux;</li><li>• Po: obstruction;</li><li>• Pr,o: reflux and obstruction;</li><li>• Pn: no venous pathophysiology identifiable.</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1030</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1030</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "With respect to clinical tests in varicose veins examination, identify the incorrect statement:", "options": [{"label": "A", "text": "In step 1 of Brodie Trendelenberg test, a rapid filling of veins from upwards indicates saphenopopliteal incompetence.", "correct": true}, {"label": "B", "text": "Step 2 of Brodie Trendelenberg test showing slow filling of veins without releasing tourniquet indicates perforator incompetence.", "correct": false}, {"label": "C", "text": "Multiple tourniquet test is used for perforator incompetence.", "correct": false}, {"label": "D", "text": "Modified Perthe’s test is used to rule out DVT.", "correct": false}], "correct_answer": "A. In step 1 of Brodie Trendelenberg test, a rapid filling of veins from upwards indicates saphenopopliteal incompetence.", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) In step 1 of Brodie Trendelenberg test, a rapid filling of veins from upwards indicates saphenopopliteal incompetence.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• In step 1, rapid filling from above downwards is suggestive of saphenofemoral incompetence.</li><li>• saphenofemoral incompetence.</li><li>• Brodie Trendelenberg test-</li><li>• Brodie Trendelenberg test-</li><li>• Patient is placed in recumbent position and his leg is raised and veins are milked to empty them . Tourniquet is tied at saphenofemoral junction and then patient is asked to stand.</li><li>• Patient is placed in recumbent position</li><li>• his leg is raised and veins are milked to empty them</li><li>• Step 1 - Release tourniquet immediately. Rapid filling from above downwards indicates SFJ incompetence.</li><li>• Step 1 -</li><li>• above downwards</li><li>• Step 2 - Do not release tourniquet on standing. Slow filling of veins indicates perforator incompetence .</li><li>• Step 2 -</li><li>• Slow filling of veins indicates perforator incompetence</li><li>• Multiple tourniquet test</li><li>• Multiple tourniquet test</li><li>• Patient is placed in recumbent position and his leg is raised and veins are milked to empty them .</li><li>• recumbent position and his leg is raised and veins are milked to empty them</li><li>• Multiple tourniquets are tied at different levels. Patient is asked to stand. Level of filling helps to understand site of perforator incompetence.</li><li>• Modified Perthe’s test - used to rule out DVT.</li><li>• Modified Perthe’s test</li><li>• A tourniquet is tied below SFJ and patient is asked to walk . If the varicosities become more prominent, it indicates DVT.</li><li>• tourniquet is tied below SFJ</li><li>• patient is asked to walk</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ To distinguish between clinical tests for varicose veins : rapid filling from above downwards in the Trendelenburg test indicates saphenofemoral junction incompetence , while slow filling with a tourniquet indicates perforator incompetence ; the Modified Perthe’s test evaluates for DVT .</li><li>➤ distinguish</li><li>➤ between</li><li>➤ clinical tests for varicose veins</li><li>➤ rapid filling from above downwards</li><li>➤ Trendelenburg test</li><li>➤ saphenofemoral junction incompetence</li><li>➤ slow filling</li><li>➤ tourniquet</li><li>➤ perforator incompetence</li><li>➤ Modified Perthe’s test</li><li>➤ DVT</li><li>➤ Ref : A Manual on Clinical Surgery by S Das 14th Edition Page 102-103</li><li>➤ Ref</li><li>➤ : A Manual on Clinical Surgery by S Das 14th Edition Page 102-103</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following vessels is not a part of the sign on USG shown below?", "options": [{"label": "A", "text": "Short Saphenous Vein", "correct": true}, {"label": "B", "text": "Great Saphenous Vein", "correct": false}, {"label": "C", "text": "Common Femoral Artery", "correct": false}, {"label": "D", "text": "Common Femoral Vein", "correct": false}], "correct_answer": "A. Short Saphenous Vein", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/27/untitled-531.jpg"], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/27/untitled-532.jpg"], "explanation": "<p><strong>Ans. A) Short Saphenous Vein</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• The sign shown here is the Mickey Mouse sign on duplex USG , which indicates normal anatomy of femoral vessels at sapheno-femoral junction . It is composed of-</li><li>• Mickey Mouse sign on duplex USG</li><li>• normal anatomy of femoral vessels at sapheno-femoral junction</li><li>• Great/Long Saphenous Vein Common Femoral Artery Common Femoral Vein</li><li>• Great/Long Saphenous Vein</li><li>• Common Femoral Artery</li><li>• Common Femoral Vein</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1031</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1031</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Find the incorrect match:", "options": [{"label": "A", "text": "Thigh- Hunterian perforator", "correct": false}, {"label": "B", "text": "Below knee- Boyd perforator", "correct": false}, {"label": "C", "text": "Ankle- Cockett perforator", "correct": true}, {"label": "D", "text": "Above knee- Dodd perforator", "correct": false}], "correct_answer": "C. Ankle- Cockett perforator", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/13/screenshot-2023-12-13-170633.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/13/picture11_B3ZL2ev.jpg"], "explanation": "<p><strong>Ans. C) Ankle- Cockett perforator</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Ankle perforator is called May or Kustner perforator . Cockett is a group of 3 perforators in calf</li><li>• Ankle perforator</li><li>• May or Kustner perforator</li><li>• Cockett</li><li>• 3 perforators in calf</li><li>• Named perforators</li><li>• Named perforators</li><li>• Ref : https://radiopaedia.org/articles/perforating-veins-of-the-lower-limb</li><li>• Ref</li><li>• :</li><li>• https://radiopaedia.org/articles/perforating-veins-of-the-lower-limb</li><li>• Sabiston Textbook of Surgery 20th Edition Page 1828</li><li>• Sabiston Textbook of Surgery 20th Edition Page 1828</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Regarding endothermal ablation techniques for varicose veins like endovenous laser ablation (EVLA) and radiofrequency ablation (RFA), pick the incorrect statement:", "options": [{"label": "A", "text": "Requires tumescent anaesthesia", "correct": false}, {"label": "B", "text": "For veins larger than 15 mm, RFA is better than EVLA", "correct": true}, {"label": "C", "text": "EVLA uses laser energy to ablate the veins", "correct": false}, {"label": "D", "text": "RFA uses electromagnetic current to ablate the veins", "correct": false}], "correct_answer": "B. For veins larger than 15 mm, RFA is better than EVLA", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) For veins larger than 15 mm, RFA is better than EVLA</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Requires tumescent anesthesia. Correct . Tumescent anesthesia involves injecting a large volume of diluted local anesthetic around the vein. It compresses the vein against the ablation device, protects surrounding tissue from heat damage by acting as a heat sink, and separates the vein from adjacent structures to prevent damage.</li><li>• Option A: Requires tumescent anesthesia. Correct</li><li>• Option C: EVLA uses laser energy to ablate the veins. Correct . EVLA uses a laser fiber that is inserted into the vein to emit laser energy. This energy heats up the blood within the vein, causing it to collapse and seal shut.</li><li>• Option C: EVLA uses laser energy to ablate the veins. Correct</li><li>• Option D: RFA uses electromagnetic current to ablate the veins. Correct . RFA involves the use of a catheter that delivers radiofrequency energy (an electromagnetic current) to heat the vein walls, causing them to collapse and eventually be reabsorbed by the body.</li><li>• Option D: RFA uses electromagnetic current to ablate the veins. Correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ EVLA is more suitable for ablating veins larger than 15 mm in diameter due to its ability to deliver efficient and consistent heat , contrasting with RFA, which is better for smaller veins.</li><li>➤ EVLA is more suitable for ablating veins larger than 15 mm in diameter</li><li>➤ ability to deliver efficient and consistent heat</li><li>➤ The basic concept of endothermal ablation is that a treatment device is inserted into the incompetent axial vein percutaneously . The vein is surrounded by tumescent local anaesthetic solution. This compresses the vein onto the treatment device, emptying it of blood. It also hydrodissects tissues such as nerves away from the zone of injury. Finally, it acts as a heat sink, mopping up excess thermal energy to prevent remote damage. The treatment device then produces thermal energy that destroys the structure of the vein , resulting in permanent occlusion .</li><li>➤ The basic concept of endothermal ablation is that a treatment device is inserted into the incompetent axial vein percutaneously . The vein is surrounded by tumescent local anaesthetic solution. This compresses the vein onto the treatment device, emptying it of blood. It also hydrodissects tissues such as nerves away from the zone of injury. Finally, it acts as a heat sink, mopping up excess thermal energy to prevent remote damage.</li><li>➤ The basic concept of endothermal ablation is that a treatment device is inserted into the incompetent axial vein percutaneously . The vein is surrounded by tumescent local anaesthetic solution. This compresses the vein onto the treatment device, emptying it of blood. It also hydrodissects tissues such as nerves away from the zone of injury. Finally, it acts as a heat sink, mopping up excess thermal energy to prevent remote damage.</li><li>➤ endothermal ablation</li><li>➤ treatment device is inserted into the incompetent axial vein percutaneously</li><li>➤ The treatment device then produces thermal energy that destroys the structure of the vein , resulting in permanent occlusion .</li><li>➤ The treatment device then produces thermal energy that destroys the structure of the vein , resulting in permanent occlusion .</li><li>➤ treatment device</li><li>➤ thermal energy</li><li>➤ destroys the structure of the vein</li><li>➤ permanent occlusion</li><li>➤ Two broad technologies exist: laser ablation and radiofrequency ablation (RFA).</li><li>➤ laser ablation and radiofrequency ablation</li><li>➤ Endovenous laser ablation (EVLA) utilises a small flexible glass fibre that is inserted into the vein and emits laser energy. RFA uses the same treatment principles, but an electromagnetic current is used to create the thermal energy for ablation. For veins larger than 15 mm, EVLA is better than RFA.</li><li>➤ Endovenous laser ablation (EVLA) utilises a small flexible glass fibre that is inserted into the vein and emits laser energy.</li><li>➤ Endovenous laser ablation (EVLA) utilises a small flexible glass fibre that is inserted into the vein and emits laser energy.</li><li>➤ RFA uses the same treatment principles, but an electromagnetic current is used to create the thermal energy for ablation.</li><li>➤ RFA uses the same treatment principles, but an electromagnetic current is used to create the thermal energy for ablation.</li><li>➤ For veins larger than 15 mm, EVLA is better than RFA.</li><li>➤ For veins larger than 15 mm, EVLA is better than RFA.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1033.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1033.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of the following are true regarding the following technique for varicose veins treatment except:", "options": [{"label": "A", "text": "It is called the Tessari technique of foam sclerotherapy.", "correct": false}, {"label": "B", "text": "Most common sclerosant used is sodium tetradecyl sulphate.", "correct": false}, {"label": "C", "text": "Ratio of sclerosant to air is 1:7-1:8.", "correct": true}, {"label": "D", "text": "Its efficacy is usually lower than endothermal ablation.", "correct": false}], "correct_answer": "C. Ratio of sclerosant to air is 1:7-1:8.", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/13/picture12_icsCVmq.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Ratio of sclerosant to air is 1:7-1:8.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Tessari Technique of Foam Sclerotherapy. This is correct . The Tessari technique is a specific method of creating foam for sclerotherapy that involves the use of two syringes and a three-way tap as seen in the given picture.</li><li>• Option A: Tessari Technique of Foam Sclerotherapy.</li><li>• correct</li><li>• Option B: Sodium Tetradecyl Sulphate as the Most Common Sclerosant. Correct . Sodium tetradecyl sulphate is indeed the most commonly used sclerosant in foam sclerotherapy. Its detergent effect causes the destruction of vein endothelial cells, leading to vein sclerosis.</li><li>• Option B: Sodium Tetradecyl Sulphate as the Most Common Sclerosant.</li><li>• Correct</li><li>• Option D: Efficacy Comparison with Endothermal Ablation. Correct . Foam sclerotherapy generally has a lower efficacy compared to endothermal ablation techniques such as EVLA or RFA, with higher rates of recurrence and potential complications.</li><li>• Option D: Efficacy Comparison with Endothermal Ablation.</li><li>• Correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Tessari technique's sclerosant-to-air ratio is 1:3 to 1:4</li><li>➤ Tessari technique's sclerosant-to-air ratio is 1:3 to 1:4</li><li>➤ Sclerotherapy is the original non-endothermal, non-tumescent technique. It involves the injection of a sclerosing agent directly into the superficial veins . The most commonly used is sodium tetradecyl sulphate. The direct contact with detergent causes cellular death and initiates an inflammatory response, aiming to result in thrombosis, fibrosis and obliteration (sclerosis). The most widely used method is that of Tessari; this utilizes two syringes connected using a three way tap. A 1:3 or 1:4 ratio mixture of sclerosant and air is drawn into one syringe, and is then oscillated vigorously between the two syringes about 10 or 20 times. The foam produced in this way is stable for about 2 minutes so it should be injected as soon as it has been made. The leg is then elevated to empty the veins of blood, and injection of foam commences first with superficial varicosities and ends with injection of the GSV or SSV. Only 1–2 mL of foam should be injected at a time. The efficacy of foam sclerotherapy is significantly worse than for endothermal ablation, leading to high reintervention rates, and the rates of complications such as phlebitis and pigmentation can be high.</li><li>➤ Sclerotherapy is the original non-endothermal, non-tumescent technique.</li><li>➤ Sclerotherapy</li><li>➤ non-endothermal, non-tumescent technique.</li><li>➤ It involves the injection of a sclerosing agent directly into the superficial veins . The most commonly used is sodium tetradecyl sulphate. The direct contact with detergent causes cellular death and initiates an inflammatory response, aiming to result in thrombosis, fibrosis and obliteration (sclerosis).</li><li>➤ injection of a sclerosing agent</li><li>➤ directly into the superficial veins</li><li>➤ sodium tetradecyl sulphate.</li><li>➤ The most widely used method is that of Tessari; this utilizes two syringes connected using a three way tap. A 1:3 or 1:4 ratio mixture of sclerosant and air is drawn into one syringe, and is then oscillated vigorously between the two syringes about 10 or 20 times. The foam produced in this way is stable for about 2 minutes so it should be injected as soon as it has been made. The leg is then elevated to empty the veins of blood, and injection of foam commences first with superficial varicosities and ends with injection of the GSV or SSV. Only 1–2 mL of foam should be injected at a time.</li><li>➤ The efficacy of foam sclerotherapy is significantly worse than for endothermal ablation, leading to high reintervention rates, and the rates of complications such as phlebitis and pigmentation can be high.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1036</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1036</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In a procedure done on a patient for varicose veins, one of the steps was flush ligation of saphenofemoral junction. Which procedure was most likely done?", "options": [{"label": "A", "text": "Dodd Cockett procedure", "correct": false}, {"label": "B", "text": "SEPS", "correct": false}, {"label": "C", "text": "Trendelenburg procedure", "correct": true}, {"label": "D", "text": "EVLA", "correct": false}], "correct_answer": "C. Trendelenburg procedure", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Trendelenburg procedure</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Dodd Cockett Procedure. Incorrect. The Dodd Cockett procedure involves subfascial ligation of perforating veins in the lower leg , not the saphenofemoral junction.</li><li>• Option A: Dodd Cockett Procedure.</li><li>• subfascial ligation of perforating veins in the lower leg</li><li>• Option B: SEPS (Subfascial Endoscopic Perforator Surgery). Also incorrect. SEPS is a minimally invasive procedure to treat incompetent perforating veins via endoscopic dissection . It does not involve ligation of the SFJ.</li><li>• Option B: SEPS (Subfascial Endoscopic Perforator Surgery).</li><li>• SEPS is a minimally invasive procedure to treat incompetent perforating veins</li><li>• endoscopic dissection</li><li>• Option D: Foam EVLA. Incorrect. It involved endoscopic ablation of GSV using a laser probe , and does not involve surgical ligation.</li><li>• Option D: Foam EVLA.</li><li>• endoscopic ablation of GSV using a laser probe</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The Trendelenburg procedure is a surgical technique involving flush ligation of the saphenofemoral junction , a key step in addressing varicose veins related to the Great Saphenous Vein .</li><li>➤ Trendelenburg procedure</li><li>➤ surgical technique</li><li>➤ flush ligation of the saphenofemoral junction</li><li>➤ addressing varicose veins</li><li>➤ Great Saphenous Vein</li><li>➤ In the Trendelenburg procedure , the GSV is identified and dissected to the SFJ .</li><li>➤ Trendelenburg procedure</li><li>➤ GSV is identified and dissected to the SFJ</li><li>➤ 6 GSV tributaries may be encountered close to the SFJ:</li><li>➤ Laterally :</li><li>➤ Laterally</li><li>➤ Superficial inferior epigastric vein; Superficial circumflex iliac vein.</li><li>➤ Superficial inferior epigastric vein; Superficial circumflex iliac vein.</li><li>➤ Superficial circumflex iliac vein.</li><li>➤ Superficial circumflex iliac vein.</li><li>➤ Medially :</li><li>➤ Medially</li><li>➤ Superficial external pudendal vein; Deep external pudendal vein.</li><li>➤ Superficial external pudendal vein; Deep external pudendal vein.</li><li>➤ Deep external pudendal vein.</li><li>➤ Deep external pudendal vein.</li><li>➤ Distally :</li><li>➤ Distally</li><li>➤ Anterior accessory of the great saphenous vein; Posteromedial thigh vein.</li><li>➤ Anterior accessory of the great saphenous vein; Posteromedial thigh vein.</li><li>➤ Posteromedial thigh vein.</li><li>➤ Posteromedial thigh vein.</li><li>➤ Classically, these are ligated distal to their divisions. A flush SFJ ligation is then performed and the GSV retrogradely(below upwards) stripped from around the knee to the thigh.</li><li>➤ Surgical procedures for varicose veins-</li><li>➤ For GSV and SFJ incompetence- EVLA/RFA (minimally invasive) Trendelenburg procedure +/- stripping - Flush ligation of SFJ and ligation of 6 tributaries For SSV and SPJ incompetence- Flush ligation of SPJ Perforator incompetence - Dodd and Crockett surgery- subfascial ligations Subfascial endoscopic perforator surgery- SEPS</li><li>➤ For GSV and SFJ incompetence- EVLA/RFA (minimally invasive) Trendelenburg procedure +/- stripping - Flush ligation of SFJ and ligation of 6 tributaries</li><li>➤ For GSV and SFJ incompetence-</li><li>➤ EVLA/RFA (minimally invasive) Trendelenburg procedure +/- stripping - Flush ligation of SFJ and ligation of 6 tributaries</li><li>➤ EVLA/RFA (minimally invasive)</li><li>➤ Trendelenburg procedure +/- stripping - Flush ligation of SFJ and ligation of 6 tributaries</li><li>➤ For SSV and SPJ incompetence- Flush ligation of SPJ</li><li>➤ For SSV and SPJ incompetence-</li><li>➤ Flush ligation of SPJ</li><li>➤ Flush ligation of SPJ</li><li>➤ Perforator incompetence - Dodd and Crockett surgery- subfascial ligations Subfascial endoscopic perforator surgery- SEPS</li><li>➤ Perforator incompetence</li><li>➤ Dodd and Crockett surgery- subfascial ligations Subfascial endoscopic perforator surgery- SEPS</li><li>➤ Dodd and Crockett surgery- subfascial ligations</li><li>➤ Subfascial endoscopic perforator surgery- SEPS</li><li>➤ Newer treatment modalities -</li><li>➤ Newer treatment modalities</li><li>➤ Endovenous glue therapy TriVex- Transilluminated powered phlebectomy</li><li>➤ Endovenous glue therapy</li><li>➤ TriVex- Transilluminated powered phlebectomy</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1036-1038</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1036-1038</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Find the incorrect statement about complications of open varicose veins surgery:", "options": [{"label": "A", "text": "Wound infection may be prevented by prophylactic antibiotics.", "correct": false}, {"label": "B", "text": "Common peroneal nerve injury may be seen.", "correct": false}, {"label": "C", "text": "Venous thromboembolic episode is a rare but serious complication.", "correct": false}, {"label": "D", "text": "Saphenous nerve neuralgia is seen associated with SSV surgery.", "correct": true}], "correct_answer": "D. Saphenous nerve neuralgia is seen associated with SSV surgery.", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Saphenous nerve neuralgia is seen associated with SSV surgery.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Wound Infection and Prophylactic Antibiotics. Correct . Prophylactic antibiotics can help prevent wound infections, which are among the most common complications following varicose vein surgery.</li><li>• Option A: Wound Infection and Prophylactic Antibiotics.</li><li>• Correct</li><li>• Option B: Common Peroneal Nerve Injury. Correct . Injury to the common peroneal nerve is a recognized complication, especially following surgery for the Small Saphenous Vein (SSV) due to its anatomical path near the nerve's location.</li><li>• Option B: Common Peroneal Nerve Injury.</li><li>• Correct</li><li>• Option C: Venous Thromboembolic Episodes. Correct . Venous thromboembolism is a rare but serious complication that can occur after any type of surgery, including varicose vein surgery, due to immobilization and changes in blood flow after the procedure.</li><li>• Option C: Venous Thromboembolic Episodes.</li><li>• Correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Saphenous nerve neuralgia is a complication associated with surgery on the Great Saphenous Vein rather than the Small Saphenous Vein , with prophylactic antibiotics reducing the risk of wound infections , and acknowledging the potential for nerve injury and venous thromboembolism as serious but less common complications.</li><li>➤ Saphenous nerve neuralgia</li><li>➤ surgery on the Great Saphenous Vein rather than the Small Saphenous Vein</li><li>➤ prophylactic antibiotics reducing the risk of wound infections</li><li>➤ potential for nerve injury</li><li>➤ venous thromboembolism</li><li>➤ Wound infections , the most common complication, are reduced by prophylactic antibiotics . Nerve injury is the most common serious complication . The incidence of saphenous nerve neuralgia is up to 7% following GSV stripping to the knee. The incidence of sural nerve neuropraxia and common peroneal nerve injury may be as high as 20% and 4%, respectively, following SSV surgery. The incidence of venous thromboembolic complications is approximately 0.5% following varicose vein surgery.</li><li>➤ Wound infections , the most common complication, are reduced by prophylactic antibiotics .</li><li>➤ Wound infections</li><li>➤ reduced by prophylactic antibiotics</li><li>➤ Nerve injury is the most common serious complication . The incidence of saphenous nerve neuralgia is up to 7% following GSV stripping to the knee.</li><li>➤ Nerve injury</li><li>➤ common serious complication</li><li>➤ The incidence of sural nerve neuropraxia and common peroneal nerve injury may be as high as 20% and 4%, respectively, following SSV surgery.</li><li>➤ The incidence of venous thromboembolic complications is approximately 0.5% following varicose vein surgery.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1038.</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1038.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "All of the following are true about the ulcer shown in the image except:", "options": [{"label": "A", "text": "Seen most commonly in lower part of leg, in the gaiter area.", "correct": false}, {"label": "B", "text": "Cause is due to ambulatory venous hypertension.", "correct": false}, {"label": "C", "text": "Has punched out edges.", "correct": true}, {"label": "D", "text": "Active venous ulcer is classified as CEAP C6", "correct": false}], "correct_answer": "C. Has punched out edges.", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/13/picture13_pKV00SP.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Has punched out edges.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Location of Venous Ulcers. Correct . Venous ulcers are most commonly seen in the lower part of the leg, specifically in the \"gaiter area,\" which includes the region above medial malleolus.</li><li>• Option A: Location of Venous Ulcers. Correct</li><li>• Option B: Cause of Venous Ulcers. Correct . Venous ulcers are typically caused by ambulatory venous hypertension, which results from the improper functioning of the venous valves in the legs and reflux of blood from deep into superficial veins.</li><li>• Option B: Cause of Venous Ulcers. Correct</li><li>• Option D: Classification of Active Venous Ulcers. Correct . An active venous ulcer is classified as CEAP C6 in the Clinical, Etiological, Anatomical, and Pathophysiological (CEAP) classification system for chronic venous disorders.</li><li>• Option D: Classification of Active Venous Ulcers. Correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The cause of a venous ulcer is ambulatory venous hypertension. A venous ulcer usually has a gently sloping edge and the floor contains granulation tissue covered by a variable amount of slough and exudate. Venous leg ulcers characteristically develop in the skin of the gaiter region , the area between the muscles of the calf and the ankle. The majority of ulcers develop on the medial side of the calf, but may develop anywhere in the gaiter area. A healed venous ulcer is C5 of CEAP classification , while an active ulcer is C6 .</li><li>➤ The cause of a venous ulcer is ambulatory venous hypertension.</li><li>➤ The cause of a venous ulcer is ambulatory venous hypertension.</li><li>➤ venous ulcer is ambulatory venous hypertension.</li><li>➤ A venous ulcer usually has a gently sloping edge and the floor contains granulation tissue covered by a variable amount of slough and exudate.</li><li>➤ A venous ulcer usually has a gently sloping edge and the floor contains granulation tissue covered by a variable amount of slough and exudate.</li><li>➤ venous ulcer</li><li>➤ gently sloping edge and the floor contains granulation tissue</li><li>➤ Venous leg ulcers characteristically develop in the skin of the gaiter region , the area between the muscles of the calf and the ankle.</li><li>➤ Venous leg ulcers characteristically develop in the skin of the gaiter region , the area between the muscles of the calf and the ankle.</li><li>➤ Venous leg ulcers</li><li>➤ skin of the gaiter region</li><li>➤ muscles of the calf and the ankle.</li><li>➤ The majority of ulcers develop on the medial side of the calf, but may develop anywhere in the gaiter area.</li><li>➤ The majority of ulcers develop on the medial side of the calf, but may develop anywhere in the gaiter area.</li><li>➤ A healed venous ulcer is C5 of CEAP classification , while an active ulcer is C6 .</li><li>➤ A healed venous ulcer is C5 of CEAP classification , while an active ulcer is C6 .</li><li>➤ healed venous ulcer is C5</li><li>➤ CEAP classification</li><li>➤ active ulcer is C6</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1040</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1040</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient who had undergone hip surgery and had a history of immobilization for 5 days, presented with complaints of unilateral calf pain and swelling. All of the following are true about the suspected condition except:", "options": [{"label": "A", "text": "May be bilateral in 30% cases", "correct": false}, {"label": "B", "text": "Can present as phlegmasia cerulea dolens or phlegmasia alba dolens", "correct": false}, {"label": "C", "text": "The first symptoms in some might be chest pain and hemoptysis", "correct": false}, {"label": "D", "text": "Clinical examination is reliable for diagnosis in this condition", "correct": true}], "correct_answer": "D. Clinical examination is reliable for diagnosis in this condition", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/27/untitled-536.jpg"], "explanation": "<p><strong>Ans. D) Clinical examination is reliable for diagnosis in this condition</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Bilateral Presentation of DVT. Correct . DVT can indeed present bilaterally in up to 30% of cases</li><li>• Option A: Bilateral Presentation of DVT.</li><li>• Correct</li><li>• Option B: Presentation as Phlegmasia Cerulea Dolens or Phlegmasia Alba Dolens. Correct . DVT can present as phlegmasia cerulea dolens (severe limb ischemia with cyanosis or painful blue limb) or phlegmasia alba dolens (less severe limb ischemia with white limb). These are severe forms of DVT.</li><li>• Option B: Presentation as Phlegmasia Cerulea Dolens or Phlegmasia Alba Dolens.</li><li>• Correct</li><li>• Option C: First Symptoms as Chest Pain and Hemoptysis. Correct . In some cases, patients with DVT may not initially exhibit symptoms related to the affected limb. Instead, their first symptoms might be related to a pulmonary embolism (PE), such as chest pain and hemoptysis.</li><li>• Option C: First Symptoms as Chest Pain and Hemoptysis.</li><li>• Correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The most common presentation of a DVT is pain and swelling, especially in the calf , usually in one leg ; however, bilateral DVTs are common , occurring in up to 30%. Some patients have no symptoms of thrombosis and may first present with signs of a pulmonary embolus, e.g., pleuritic chest pain, haemoptysis and shortness of breath. Patients may also develop shortness of breath from chronic pulmonary hypertension . Sometimes the leg appears cellulitic and very occasionally it may be white or cyanosed: phlegmasia alba dolens and phlegmasia cerulea dolens. This indicates venous pressures that are so high they are impeding tissue perfusion. Clinical examination for DVT is unreliable. Physical signs may also be absent.</li><li>➤ The most common presentation of a DVT is pain and swelling, especially in the calf , usually in one leg ; however, bilateral DVTs are common , occurring in up to 30%.</li><li>➤ DVT is pain and swelling,</li><li>➤ calf</li><li>➤ one leg</li><li>➤ bilateral DVTs are common</li><li>➤ Some patients have no symptoms of thrombosis and may first present with signs of a pulmonary embolus, e.g., pleuritic chest pain, haemoptysis and shortness of breath.</li><li>➤ Some patients have no symptoms of thrombosis</li><li>➤ Patients may also develop shortness of breath from chronic pulmonary hypertension .</li><li>➤ shortness of breath from chronic pulmonary hypertension</li><li>➤ Sometimes the leg appears cellulitic and very occasionally it may be white or cyanosed: phlegmasia alba dolens and phlegmasia cerulea dolens. This indicates venous pressures that are so high they are impeding tissue perfusion.</li><li>➤ Clinical examination for DVT is unreliable. Physical signs may also be absent.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1044</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1044</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient presented with pain and swelling in calf region 2 weeks after undergoing a hip surgery. There was pitting edema of calf on examination. According to the modified Well’s criteria, the score was 3. What is the probability that he has deep vein thrombosis?", "options": [{"label": "A", "text": "No probability", "correct": false}, {"label": "B", "text": "Low probability", "correct": false}, {"label": "C", "text": "Moderate probability", "correct": false}, {"label": "D", "text": "High probability", "correct": true}], "correct_answer": "D. High probability", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/13/screenshot-2023-12-13-172629_pfYeKek.jpg"], "explanation": "<p><strong>Ans. D) High probability</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• A score of more than two indicates high probability of deep vein thrombosis according to the modified Well’s criteria .</li><li>• score of more than two</li><li>• high probability of deep vein thrombosis</li><li>• modified Well’s criteria</li><li>• Hip surgery: 1 point</li><li>• Hip surgery: 1 point</li><li>• Pain and swelling: 1 point</li><li>• Pain and swelling: 1 point</li><li>• Pitting edema: 1 point</li><li>• Pitting edema: 1 point</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Modified Well’s criteria for predicting deep vein thrombosis-</li><li>• Score -2 to 0 - low probability</li><li>• -2 to 0 - low probability</li><li>• 1 or 2 - moderate probability</li><li>• 1 or 2 - moderate probability</li><li>• &gt;2 - high probability</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1044</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1044</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient presented with chest pain and acute shortness of breath. There was also pain and swelling in the calf region. He has a past history of DVT. His heart rate on examination was 107/min. There was no history of immobilisation or surgery, no history of haemoptysis. He was not a known case of any malignancy. What is the likely diagnosis?", "options": [{"label": "A", "text": "Pulmonary embolism", "correct": true}, {"label": "B", "text": "Myocardial infarction", "correct": false}, {"label": "C", "text": "Pleural effusion", "correct": false}, {"label": "D", "text": "Aortic dissection", "correct": false}], "correct_answer": "A. Pulmonary embolism", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/13/screenshot-2023-12-13-173055.jpg"], "explanation": "<p><strong>Ans. A) Pulmonary embolism</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Option B: Myocardial Infarction (MI). Incorrect. While chest pain and an elevated heart rate can be associated with myocardial infarction (MI), the presence of calf pain and swelling , along with a history of DVT, makes PE a more likely diagnosis in this case.</li><li>• Option B: Myocardial Infarction (MI).</li><li>• chest pain</li><li>• elevated heart rate</li><li>• associated with myocardial infarction</li><li>• presence of calf pain and swelling</li><li>• Option C: Pleural Effusion. Incorrect. Pleural effusion typically presents with chest pain and difficulty breathing , but it does not explain the calf pain and swelling or the patient's history of DVT.</li><li>• Option C: Pleural Effusion.</li><li>• Pleural effusion</li><li>• chest pain</li><li>• difficulty breathing</li><li>• Option D: Aortic Dissection. Incorrect. Aortic dissection can also cause chest pain radiating to scapula and shortness of breath , but it is less likely in the absence of risk factors such as hypertension or connective tissue disorders . Additionally, it does not account for the calf symptoms or DVT history.</li><li>• Option D: Aortic Dissection.</li><li>• cause chest pain radiating to scapula and shortness of breath</li><li>• less likely in the absence of risk factors such as hypertension or connective tissue disorders</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The clinical presentation and risk factors associated with pulmonary embolism (PE) includes chest pain , acute shortness of breath , and an elevated heart rate , especially in individuals with a history of deep vein thrombosis (DVT).</li><li>➤ pulmonary embolism</li><li>➤ chest pain</li><li>➤ acute shortness of breath</li><li>➤ elevated heart rate</li><li>➤ Modified Well ’ s criteria for predicting pulmonary embolism-</li><li>➤ Score &gt; 4 - PE likely</li><li>➤ &lt; 4 - unlikely</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1045</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1045</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "True statement about use of compression stockings in varicose veins:", "options": [{"label": "A", "text": "No benefit in preventing or progression of disease", "correct": true}, {"label": "B", "text": "Class I stockings are used in venous ulcer", "correct": false}, {"label": "C", "text": "Provide equal improvements in QoL and cost- effective compared to surgery", "correct": false}, {"label": "D", "text": "Minimal improvement in symptoms", "correct": false}], "correct_answer": "A. No benefit in preventing or progression of disease", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) No benefit in preventing or progression of disease</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Class I stockings are used in venous ulcer. Incorrect. Class II or III stockings are typically used in the management of venous ulcers , as they exert a higher pressure compared to Class I stockings.</li><li>• Option B: Class I stockings are used in venous ulcer.</li><li>• Class II or III stockings are typically used in the management of venous ulcers</li><li>• Option C: Provide equal improvements in QoL and cost-effective compared to surgery. Incorrect. While compression stockings can improve quality of life and are cost-effective , they are not considered equal to surgery in terms of efficacy , especially for advanced cases of varicose veins.</li><li>• Option C: Provide equal improvements in QoL and cost-effective compared to surgery.</li><li>• compression stockings can improve quality of life and are cost-effective</li><li>• not considered equal to surgery in terms of efficacy</li><li>• Option D: Minimal improvement in symptoms. Incorrect. Compression stockings can provide significant improvement in varicose vein symptoms , although patient compliance can be an issue.</li><li>• Option D: Minimal improvement in symptoms.</li><li>• Compression stockings</li><li>• improvement in varicose vein symptoms</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Compression stockings can help alleviate symptoms of varicose veins but do not prevent or stop the progression of the disease . They are a conservative management option for symptom relief.</li><li>➤ Compression stockings</li><li>➤ alleviate symptoms of varicose veins</li><li>➤ do not prevent or stop the progression of the disease</li><li>➤ Compression hosiery relies on graduated external pressure to improve deep venous return and reduce venous pressures . It may be knee length or thigh length; there is no evidence which length of stocking is more effective and hence below-knee stockings are usually prescribed as they are easier to don and have much better patient acceptance. Compression hosiery is classified according to the pressure it exerts : the British classification class 1 stockings exert pressure of 14–17 mmHg, class 2 exert 18–24 mmHg and class 3 exert 25–35 mmHg. Compression hosiery significantly improves varicose vein symptoms but is not popular with patients, with compliance rates and long-term tolerance being universally poor. There is no evidence to suggest that compression hosiery prevents the occurrence or progression of varicose veins.</li><li>➤ Compression hosiery relies on graduated external pressure to improve deep venous return and reduce venous pressures . It may be knee length or thigh length; there is no evidence which length of stocking is more effective and hence below-knee stockings are usually prescribed as they are easier to don and have much better patient acceptance.</li><li>➤ Compression hosiery relies on graduated external pressure</li><li>➤ deep venous return</li><li>➤ reduce venous pressures</li><li>➤ Compression hosiery is classified according to the pressure it exerts : the British classification class 1 stockings exert pressure of 14–17 mmHg, class 2 exert 18–24 mmHg and class 3 exert 25–35 mmHg.</li><li>➤ Compression hosiery</li><li>➤ pressure it exerts</li><li>➤ Compression hosiery significantly improves varicose vein symptoms but is not popular with patients, with compliance rates and long-term tolerance being universally poor.</li><li>➤ There is no evidence to suggest that compression hosiery prevents the occurrence or progression of varicose veins.</li><li>➤ There is no evidence to suggest that compression hosiery prevents the occurrence or progression of varicose veins.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A 45-year-old man with diabetes mellitus underwent a anterior rectal resection surgery for carcinoma. To prevent post-operative venous thromboembolism, what method is recommended in this case?", "options": [{"label": "A", "text": "Compression stockings only", "correct": false}, {"label": "B", "text": "Compression stockings and pharmacological prophylaxis", "correct": true}, {"label": "C", "text": "No need for any prophylaxis", "correct": false}, {"label": "D", "text": "IVC filter", "correct": false}], "correct_answer": "B. Compression stockings and pharmacological prophylaxis", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Compression stockings and pharmacological prophylaxis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• This patient falls into high risk according to the risk stratification for DVT . Thus, dual prophylaxis is generally recommended in such cases to prevent venous thromboembolism.</li><li>• falls into high risk</li><li>• risk stratification for DVT</li><li>• dual prophylaxis</li><li>• prevent venous thromboembolism.</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Low, medium and high-risk patient groups for venous thromboembolism-</li><li>➤ Low risk -</li><li>➤ Low risk</li><li>➤ Minor surgery &lt;30 minutes; any age; no risk factors Major surgery &gt;30 minutes; age &lt;40; no other risk factors Minor trauma or medical illness</li><li>➤ Minor surgery &lt;30 minutes; any age; no risk factors</li><li>➤ Major surgery &gt;30 minutes; age &lt;40; no other risk factors</li><li>➤ Minor trauma or medical illness</li><li>➤ Medium risk -</li><li>➤ Medium risk</li><li>➤ Major surgery; age 40+ or other risk factors Major medical illness: heart/lung disease, cancer, inflammatory bowel disease Major trauma/burns Minor surgery, trauma, medical illness in patient with previous DVT, PE or thrombophilia</li><li>➤ Major surgery; age 40+ or other risk factors</li><li>➤ Major medical illness: heart/lung disease, cancer, inflammatory bowel disease</li><li>➤ Major trauma/burns Minor surgery, trauma, medical illness in patient with previous DVT, PE or thrombophilia</li><li>➤ Minor surgery, trauma, medical illness in patient with previous DVT, PE or thrombophilia</li><li>➤ Minor surgery, trauma, medical illness in patient with previous DVT, PE or thrombophilia</li><li>➤ High risk -</li><li>➤ High risk</li><li>➤ Major orthopaedic surgery or fracture of pelvis, hip, lower limb. Major abdominal/pelvic surgery for cancer Major surgery, trauma, medical illness in patient with DVT, PE or thrombophilia Lower limb paralysis (e.g., stroke, paraplegia) Major lower limb amputation</li><li>➤ Major orthopaedic surgery or fracture of pelvis, hip, lower limb.</li><li>➤ Major abdominal/pelvic surgery for cancer Major surgery, trauma, medical illness in patient with DVT, PE or thrombophilia Lower limb paralysis (e.g., stroke, paraplegia)</li><li>➤ Major surgery, trauma, medical illness in patient with DVT, PE or thrombophilia Lower limb paralysis (e.g., stroke, paraplegia)</li><li>➤ Major surgery, trauma, medical illness in patient with DVT, PE or thrombophilia</li><li>➤ Lower limb paralysis (e.g., stroke, paraplegia)</li><li>➤ Major lower limb amputation</li><li>➤ For low risk group- mechanical prophylaxis</li><li>➤ Medium and high risk- mechanical plus pharmacological prophylaxis</li><li>➤ Mechanical prophylaxis-</li><li>➤ Mechanical prophylaxis-</li><li>➤ Graded compression stockings External pneumatic compression</li><li>➤ Graded compression stockings</li><li>➤ External pneumatic compression</li><li>➤ Pharmacological prophylaxis-</li><li>➤ Pharmacological prophylaxis-</li><li>➤ Anticoagulants like LMWH/Enoxaparin.</li><li>➤ Anticoagulants like LMWH/Enoxaparin.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1045-46</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1045-46</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Regarding the treatment of DVT, find the incorrect statement:", "options": [{"label": "A", "text": "LMWH and warfarin is given for the first 5 days after which warfarin is continued.", "correct": false}, {"label": "B", "text": "First episode of DVT requires continuation of treatment for a minimum of 12 months.", "correct": true}, {"label": "C", "text": "In case of contraindications to anticoagulation, IVC filter can be used.", "correct": false}, {"label": "D", "text": "Patients with ilio-femoral thrombosis may benefit from endovascular surgery.", "correct": false}], "correct_answer": "B. First episode of DVT requires continuation of treatment for a minimum of 12 months.", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) First episode of DVT requires continuation of treatment for a minimum of 12 months.</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: LMWH and warfarin is given for the first 5 days after which warfarin is continued. Correct . LMWH and warfarin are commonly used for the initial treatment of DVT. LMWH is given for the first 5 days to rapidly anticoagulate the patient, after which warfarin is continued.</li><li>• Option A: LMWH and warfarin is given for the first 5 days after which warfarin is continued.</li><li>• Correct</li><li>• Option C: In case of contraindications to anticoagulation, IVC filter can be used. Correct . In cases where anticoagulation is contraindicated or not tolerated, an inferior vena cava (IVC) filter can be considered as an alternative to prevent pulmonary embolism.</li><li>• Option C: In case of contraindications to anticoagulation, IVC filter can be used.</li><li>• Correct</li><li>• Option D: Patients with iliofemoral thrombosis may benefit from endovascular surgery. Correct . Patients with iliofemoral thrombosis may benefit from endovascular surgery, including thrombus removal, lysis, and stenting techniques, to reduce the risk of chronic post-thrombotic syndrome.</li><li>• Option D: Patients with iliofemoral thrombosis may benefit from endovascular surgery.</li><li>• Correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Patients who are confirmed to have a DVT on duplex imaging should be rapidly anticoagulated with a ‘ treatment dose ’ of subcutaneous LMWH . Warfarin is started simultaneously and after 5 days, LMWH is stopped and warfarin given. Patients with significant renal impairment should be commenced on intravenous unfractionated heparin. Patients who have a sensitivity towards heparinoids , such as those with heparin-induced thrombocytopenia , should commence on another anticoagulant, such as fondaparinux (an indirect factor Xa inhibitor) or bivalirudin (a direct thrombin inhibitor). This will achieve rapid anticoagulation and reduce the risk of embolisation. Typically, patients will then commence on oral anticoagulation for at least 3 months (or longer depending upon the persistence of risk factors or in recurrent cases). Oral anticoagulation using new or ‘ novel ’ anticoagulants (NOACs), which directly inhibit either factor Xa (rivaroxaban and apixaban) or thrombin (dabigatran), is recommended as they are equally effective as vitamin K antagonists (warfarin) in preventing recurrent symptomatic VTE but are associated with less major bleeding complications. Patients who cannot be safely anticoagulated (usually because of bleeding risks) should be considered for a temporary inferior vena cava filter Endovascular surgery aiming to restore patency, including thrombus removal, lysis and stenting techniques, are increasingly used in patients with acute DVT aiming to reduce the risk of chronic post-thrombotic syndrome. Research suggests this may be beneficial in selected patients, for example in iliofemoral thrombosis.</li><li>➤ Patients who are confirmed to have a DVT on duplex imaging should be rapidly anticoagulated with a ‘ treatment dose ’ of subcutaneous LMWH . Warfarin is started simultaneously and after 5 days, LMWH is stopped and warfarin given.</li><li>➤ DVT on duplex imaging should be rapidly anticoagulated with a</li><li>➤ treatment dose</li><li>➤ of subcutaneous LMWH</li><li>➤ Patients with significant renal impairment should be commenced on intravenous unfractionated heparin.</li><li>➤ renal impairment</li><li>➤ intravenous unfractionated heparin.</li><li>➤ Patients who have a sensitivity towards heparinoids , such as those with heparin-induced thrombocytopenia , should commence on another anticoagulant, such as fondaparinux (an indirect factor Xa inhibitor) or bivalirudin (a direct thrombin inhibitor). This will achieve rapid anticoagulation and reduce the risk of embolisation.</li><li>➤ sensitivity towards heparinoids</li><li>➤ heparin-induced thrombocytopenia</li><li>➤ Typically, patients will then commence on oral anticoagulation for at least 3 months (or longer depending upon the persistence of risk factors or in recurrent cases).</li><li>➤ Oral anticoagulation using new or ‘ novel ’ anticoagulants (NOACs), which directly inhibit either factor Xa (rivaroxaban and apixaban) or thrombin (dabigatran), is recommended as they are equally effective as vitamin K antagonists (warfarin) in preventing recurrent symptomatic VTE but are associated with less major bleeding complications.</li><li>➤ Patients who cannot be safely anticoagulated (usually because of bleeding risks) should be considered for a temporary inferior vena cava filter</li><li>➤ Endovascular surgery aiming to restore patency, including thrombus removal, lysis and stenting techniques, are increasingly used in patients with acute DVT aiming to reduce the risk of chronic post-thrombotic syndrome. Research suggests this may be beneficial in selected patients, for example in iliofemoral thrombosis.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1046</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 1046</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of the following is the most common aetiology of lymphedema?", "options": [{"label": "A", "text": "Malignancy", "correct": false}, {"label": "B", "text": "Lymphatic filariasis", "correct": true}, {"label": "C", "text": "Congenital lymphedema", "correct": false}, {"label": "D", "text": "Post Mastectomy", "correct": false}], "correct_answer": "B. Lymphatic filariasis", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) Lymphatic filariasis</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Malignancy - Many cases of secondary lymphoedema are related to malignancy or its treatment , including most commonly breast cancer, melanoma, gynaecological malignancies, lymphoma and urological cancers . Radiotherapy and lymph node dissection/resection are also causes of secondary lymphoedema.</li><li>• Option A: Malignancy</li><li>• secondary lymphoedema</li><li>• malignancy or its treatment</li><li>• breast cancer, melanoma, gynaecological malignancies, lymphoma and urological cancers</li><li>• Other causes - These include trauma, tuberculosis and lymphogranuloma venereum, a chronic lymphatic infection with Chlamydia trachomatis, which is spread through sexual contact.</li><li>• Other causes -</li><li>• Primary lymphoedema is rare . It is classified as</li><li>• Primary lymphoedema is rare</li><li>• Congenital (age &lt; 1 year)</li><li>• Praecox (age 2-35 years)</li><li>• Tarda (age &gt; 35 years)</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Chapter 62A</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Chapter 62A</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "A patient presented with lymphedema which was of non-pitting type and does not resolve with elevation of limb. How would you grade this lymphedema?", "options": [{"label": "A", "text": "Subclinical", "correct": false}, {"label": "B", "text": "Mild", "correct": false}, {"label": "C", "text": "Moderate", "correct": true}, {"label": "D", "text": "Severe", "correct": false}], "correct_answer": "C. Moderate", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/13/screenshot-2023-12-13-174942.jpg", "https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/27/untitled-540.jpg"], "explanation": "<p><strong>Ans. C) Moderate</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Brunner’s Stages of lymphedema-</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Chapter 62A</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Chapter 62A</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "While examining a patient with lymphedema, the doctor was unable to pinch a fold of skin on the dorsum of the toes. What is this sign called?", "options": [{"label": "A", "text": "Stemmer sign", "correct": true}, {"label": "B", "text": "Homan sign", "correct": false}, {"label": "C", "text": "Moses sign", "correct": false}, {"label": "D", "text": "Pratt sign", "correct": false}], "correct_answer": "A. Stemmer sign", "question_images": [], "explanation_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/12/13/screenshot-2023-12-13-175522.jpg"], "explanation": "<p><strong>Ans. A) Stemmer sign</strong></p>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these causes of edema classically show the following appearance?", "options": [{"label": "A", "text": "Venous cause", "correct": false}, {"label": "B", "text": "Arterial cause", "correct": false}, {"label": "C", "text": "Cardiac cause", "correct": false}, {"label": "D", "text": "Lymphatic cause", "correct": true}], "correct_answer": "D. Lymphatic cause", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/27/untitled-541.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. D) Lymphatic cause</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• This image shows the classic buffalo hump (foot) and tree trunk seen (leg) in severe lymphedema.</li><li>• classic buffalo hump</li><li>• tree trunk seen</li><li>• severe lymphedema.</li><li>• Clinical features of lymphedema-</li><li>• Clinical features of lymphedema-</li><li>• Symptoms-</li><li>• Symptoms-</li><li>• Slowly progressive limb swelling that usually begins distally and may progress during the day. It is often precipitated by prolonged standing and is relieved by elevation and compression garments.</li><li>• Slowly progressive limb swelling that usually begins distally and may progress during the day. It is often precipitated by prolonged standing and is relieved by elevation and compression garments.</li><li>• Slowly progressive limb swelling</li><li>• Signs-</li><li>• Signs-</li><li>• limb swelling, which is initially pitting but with time becomes non-pitting because of subcutaneous fibrosis Squaring of toes Skin changes like peau d’orange, erythema / cellulitis, hyperkeratosis, eczema, fungal infection, ulceration etc Stemmer’s sign Buffalo hump on dorsum of foot Scars from previous trauma or surgery and post-radiotherapy telangiectasia in patients of secondary lymphedema</li><li>• limb swelling, which is initially pitting but with time becomes non-pitting because of subcutaneous fibrosis</li><li>• Squaring of toes</li><li>• Squaring of toes</li><li>• Skin changes like peau d’orange, erythema / cellulitis, hyperkeratosis, eczema, fungal infection, ulceration etc</li><li>• Stemmer’s sign</li><li>• Stemmer’s sign</li><li>• Buffalo hump on dorsum of foot</li><li>• Buffalo hump on dorsum of foot</li><li>• Scars from previous trauma or surgery and post-radiotherapy telangiectasia in patients of secondary lymphedema</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Chapter 62A</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Chapter 62A</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the incorrect statement about lymphoscintigraphy is lymphedema:", "options": [{"label": "A", "text": "Low sensitivity and specificity for lymphedema", "correct": true}, {"label": "B", "text": "Radiolabelled colloid injected into web spaces", "correct": false}, {"label": "C", "text": "Abnormalities are suggested by delayed transit, prominent collaterals, dermal backflow", "correct": false}, {"label": "D", "text": "It has now largely replaced contrast lymphangiography", "correct": false}], "correct_answer": "A. Low sensitivity and specificity for lymphedema", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. A) Low sensitivity and specificity for lymphedema</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option B: Radiolabeled colloid is injected into web spaces. Correct . Lymphoscintigraphy involves injecting radiolabeled colloid into the web spaces to assess lymphatic function.</li><li>• Option B: Radiolabeled colloid is injected into web spaces.</li><li>• Correct</li><li>• Option C: Abnormalities are suggested by delayed transit, prominent collaterals, dermal backflow. Correct . Lymphoscintigraphy detects lymphatic abnormalities through various indicators such as delayed transit, prominent collaterals, and dermal backflow.</li><li>• Option C: Abnormalities are suggested by delayed transit, prominent collaterals, dermal backflow.</li><li>• Correct</li><li>• Option D: It has now largely replaced contrast lymphangiography. Correct . Lymphoscintigraphy is the preferred diagnostic method and has largely replaced contrast lymphangiography.</li><li>• Option D: It has now largely replaced contrast lymphangiography.</li><li>• Correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ Lymphoscintigraphy is a highly sensitive and specific diagnostic tool for lymphedema , involving the injection of radiolabeled colloid and the assessment of lymphatic abnormalities , and it has largely replaced contrast lymphangiography.</li><li>➤ Lymphoscintigraphy</li><li>➤ highly sensitive and specific diagnostic tool for lymphedema</li><li>➤ injection of radiolabeled colloid</li><li>➤ assessment of lymphatic abnormalities</li><li>➤ largely replaced contrast lymphangiography.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Chapter 62A</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Chapter 62A</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Read the following statements regarding the treatment of lymphedema and classify them as true or false: Arterial insufficiency is a contraindication to compression therapy in lymphedema. Long term diuretics are of benefit and recommended. Skin care is an important part of management. Drug of choice for filarial infection is albendazole.", "options": [{"label": "A", "text": "T T T T", "correct": false}, {"label": "B", "text": "T F T F", "correct": true}, {"label": "C", "text": "T F T T", "correct": false}, {"label": "D", "text": "F T T F", "correct": false}], "correct_answer": "B. T F T F", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. B) T F T F</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation</li><li>• Arterial insufficiency is a contraindication to compression therapy in lymphedema. – True</li><li>• Arterial insufficiency is a contraindication to compression therapy in lymphedema. – True</li><li>• In cases of lymphedema , compression therapy , such as the use of compression garments or bandages , is commonly used to reduce swelling and improve lymphatic drainage . However, in the presence of arterial insufficiency, applying external pressure through compression therapy can further compromise arterial blood flow, potentially leading to tissue damage and worsening of the condition.</li><li>• lymphedema</li><li>• compression therapy</li><li>• use of compression garments or bandages</li><li>• reduce swelling and improve lymphatic drainage</li><li>• Option B. Long-term diuretics are of benefit and recommended. – False While diuretics may be useful in certain conditions , such as congestive heart failure or hypertension , they are generally not recommended for the treatment of lymphedema . Lymphedema is primarily characterized by the accumulation of lymphatic fluid in the affected limb, and diuretics do not address the underlying issue of impaired lymphatic drainage. In fact, diuretics can lead to dehydration and electrolyte imbalances without providing significant benefit in reducing lymphedema. Therefore, long-term diuretic use is not considered beneficial or recommended for lymphedema management.</li><li>• Option B. Long-term diuretics are of benefit and recommended. – False</li><li>• diuretics may be useful in certain conditions</li><li>• congestive heart failure or hypertension</li><li>• generally not recommended for the treatment of lymphedema</li><li>• Option C: Skin care is an important part of management. – True Individuals with lymphedema are at an increased risk of skin-related complications , including infections and cellulitis . Proper skin care helps maintain the health and integrity of the skin in the affected limb, reducing the risk of complications.</li><li>• Option C: Skin care is an important part of management. – True Individuals</li><li>• lymphedema are at an increased risk of skin-related complications</li><li>• infections and cellulitis</li><li>• Option D: Drug of choice for filarial infection is albendazole. – False Albendazole is an anthelmintic medication used to treat various parasitic worm infections , but it is not the drug of choice for filarial infections caused by filarial worms such as Wuchereria bancrofti or Brugia malayi. The primary drug of choice for treating filarial infections is diethylcarbamazine (DEC).</li><li>• Option D: Drug of choice for filarial infection is albendazole. – False Albendazole</li><li>• anthelmintic medication used to treat various parasitic worm infections</li><li>• not the drug of choice for filarial infections caused by filarial worms such as Wuchereria bancrofti</li><li>• Educational objective:</li><li>• Educational objective:</li><li>• Medical / non-surgical management</li><li>• Medical / non-surgical management</li><li>• This improves lymphatic drainage . It includes simple elevation, manual lymphatic drainage, compression, exercise and skincare. Manual lymphatic drainage involves the proximal massage of fluid along the lymphatic channels. Compression can be achieved with multi-layer bandaging, compression garments and intermittent pneumatic compression. Arterial insufficiency is the main contraindication to compression therapy. Diuretics may reduce swelling in the short-term but long-term therapy is of no value and should be avoided. Antibiotics/antifungals guided by microbiological culture may be required for cellulitis and fungal foot infections . Underlying filarial infection requires treatment with diethylcarbamazine.</li><li>• This improves lymphatic drainage . It includes simple elevation, manual lymphatic drainage, compression, exercise and skincare. Manual lymphatic drainage involves the proximal massage of fluid along the lymphatic channels.</li><li>• improves lymphatic drainage</li><li>• Compression can be achieved with multi-layer bandaging, compression garments and intermittent pneumatic compression. Arterial insufficiency is the main contraindication to compression therapy.</li><li>• Diuretics may reduce swelling in the short-term but long-term therapy is of no value and should be avoided. Antibiotics/antifungals guided by microbiological culture may be required for cellulitis and fungal foot infections .</li><li>• Underlying filarial infection requires treatment with diethylcarbamazine.</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Chapter 62A</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Chapter 62A</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Identify the surgical procedure done below in a case of debilitating lymphedema:", "options": [{"label": "A", "text": "Homan limb reduction surgery", "correct": false}, {"label": "B", "text": "Liposuction", "correct": false}, {"label": "C", "text": "Charles limb reduction surgery", "correct": true}, {"label": "D", "text": "Kinmonth procedure", "correct": false}], "correct_answer": "C. Charles limb reduction surgery", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/30/vascular-surgery-18.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. C) Charles limb reduction surgery</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Surgical procedures for lymphedema-</li><li>• Bypass/Reconstructive procedures-</li><li>• Bypass/Reconstructive procedures-</li><li>• Neilubowicz procedure- anastomoses of lymph nodes to veins Kinmonth procedure- uses ileal mucosal patch</li><li>• Neilubowicz procedure- anastomoses of lymph nodes to veins</li><li>• Kinmonth procedure- uses ileal mucosal patch</li><li>• Limb reduction surgery-</li><li>• Limb reduction surgery-</li><li>• Sistrunk procedure- wedge of skin and subcutaneous tissue excised and primary closure done. Charles procedure- All skin and subcutaneous tissue is excised upto deep fascia and covered with split thickness skin grafts. Homan’s procedure- Skin flaps raised and subcutaneous tissue excised.</li><li>• Sistrunk procedure- wedge of skin and subcutaneous tissue excised and primary closure done.</li><li>• Charles procedure- All skin and subcutaneous tissue is excised upto deep fascia and covered with split thickness skin grafts.</li><li>• Charles procedure- All skin and subcutaneous tissue is excised upto deep fascia and covered with split thickness skin grafts.</li><li>• Homan’s procedure- Skin flaps raised and subcutaneous tissue excised.</li><li>• Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Chapter 62A</li><li>• Ref</li><li>• : Bailey and Love’s Short Practice of Surgery 28th Edition Chapter 62A</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "An infant presented with the following neck swelling which was brilliantly transilluminant. All of the following are true about this condition except:", "options": [{"label": "A", "text": "Can cause obstructed labour", "correct": false}, {"label": "B", "text": "Filled with clear lymph and lined by single layer of epithelium", "correct": false}, {"label": "C", "text": "May expand rapidly or get infected", "correct": false}, {"label": "D", "text": "Treatment is mainly pharmacological", "correct": true}], "correct_answer": "D. Treatment is mainly pharmacological", "question_images": ["https://cerebellum-web-static.s3.amazonaws.com/media/public/images/2023/05/27/untitled-543.jpg"], "explanation_images": [], "explanation": "<p><strong>Ans. D) Treatment is mainly pharmacological</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: Can cause obstructed labour. Correct . Cystic hygroma, when present in the fetal or neonatal neck region, can become large enough to obstruct the birth canal during labor, leading to obstructed labor.</li><li>• Option A: Can cause obstructed labour.</li><li>• Correct</li><li>• Option B: Filled with clear lymph and lined by a single layer of epithelium. Correct . Cystic hygroma is typically filled with clear lymphatic fluid and is lined by a single layer of epithelium.</li><li>• Option B: Filled with clear lymph and lined by a single layer of epithelium.</li><li>• Correct</li><li>• Option C: May expand rapidly or get infected. Correct . Cystic hygromas can expand rapidly, and they are also susceptible to infection.</li><li>• Option C: May expand rapidly or get infected.</li><li>• Correct</li></ul>\n<p><strong>Educational Objective:</strong></p><ul><li>➤ Educational Objective:</li><li>➤ The characteristics and clinical implications of cystic hygroma , including its potential to cause obstructed labour , its composition (clear lymph and single-layer epithelium lining), the risk of rapid expansion and infection , and the primary treatment approach involving surgical excision or sclerosing agent injection .</li><li>➤ characteristics and clinical implications of cystic hygroma</li><li>➤ potential to cause obstructed labour</li><li>➤ composition</li><li>➤ risk of rapid expansion and infection</li><li>➤ primary treatment approach involving surgical excision or sclerosing agent injection</li><li>➤ Cystic hygromas usually present in the neonate or in early infancy . Occasionally they may be so large that they can obstruct labour. The cyst is filled with clear lymph and lined by a single layer of epithelium. Swelling usually occurs in the neck and may involve the face, submandibular region, tongue and floor of mouth.</li><li>➤ Cystic hygromas</li><li>➤ neonate or in early infancy</li><li>➤ The characteristic that distinguishes it from all other neck swellings is that it is brilliantly trans illuminant . Sometimes the cyst expands rapidly and occasionally respiratory difficulty may occur. The cyst may also become infected.</li><li>➤ The characteristic that distinguishes it from all other neck swellings is that it is brilliantly trans illuminant .</li><li>➤ Sometimes the cyst expands rapidly and occasionally respiratory difficulty may occur. The cyst may also become infected.</li><li>➤ Ref : Bailey and Love’s Short Practice of Surgery 28th Edition Page 805-806</li><li>➤ Ref</li><li>➤ : Bailey and Love’s Short Practice of Surgery 28th Edition Page 805-806</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "Which of these is the most likely explanation for venous ulcer in patient with varicose veins?", "options": [{"label": "A", "text": "Fibrin cuff hypothesis", "correct": false}, {"label": "B", "text": "White cell trapping hypothesis", "correct": false}, {"label": "C", "text": "Tissue anoxia", "correct": false}, {"label": "D", "text": "Ambulatory venous hypertension", "correct": true}], "correct_answer": "D. Ambulatory venous hypertension", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. D) Ambulatory venous hypertension</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Option A: High venous pressure was found to be associated with a pericapillary infiltrate . This includes fibrin and other proteins , which are known to lead to fibrosis . It was hypothesised that these ‘cuffs’ could act as an impediment to diffusion of oxygen and nutrients.</li><li>• Option A:</li><li>• High venous pressure</li><li>• associated with a pericapillary infiltrate</li><li>• fibrin and other proteins</li><li>• lead to fibrosis</li><li>• Option B: Leukocytes were found to be reduced in the blood returning from legs with venous hypertension. This decrease in leukocyte passage was shown to increase if short-term venous hypertension was induced by application of a tourniquet . This led to the concept of white cell ‘trapping’, which, however, has not been confirmed by further investigation.</li><li>• Option B:</li><li>• Leukocytes were found to be reduced in the blood returning from legs</li><li>• venous hypertension.</li><li>• decrease in leukocyte passage</li><li>• increase if short-term venous hypertension</li><li>• induced by application of a tourniquet</li><li>• Option C: Originally, it was thought that static blood within the superficial veins led to hypoxia , which caused tissue death (stasis ulcers). This was not confirmed by investigation of venous oxygen saturation, which was found to be higher in ulcerated limbs</li><li>• Option C:</li><li>• static blood within the superficial veins led to hypoxia</li><li>• caused tissue death</li><li>• Ref : Bailey and Lover 28 th Ed. Pg 1059-60 .</li><li>• Ref</li><li>• : Bailey and Lover 28 th Ed. Pg 1059-60</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}, {"text": "In a patient with venous ulcer, the following components are proven to be beneficial in the management except?", "options": [{"label": "A", "text": "High pressure compression stocking", "correct": false}, {"label": "B", "text": "EVLA", "correct": false}, {"label": "C", "text": "Anticoagulation", "correct": true}, {"label": "D", "text": "Pentoxyphylline", "correct": false}], "correct_answer": "C. Anticoagulation", "question_images": [], "explanation_images": [], "explanation": "<p><strong>Ans. C) Anticoagulation</strong></p>\n<p><strong>Explanation:</strong></p><ul><li>• Explanation:</li><li>• Anticoagulation is used in management of DVT</li><li>• Anticoagulation</li><li>• management of DVT</li><li>• The cause of a venous leg ulcer is venous hypertension and the keystone of management is to decrease this hypertension using venous ablation (Option B) and compression therapy. Pentoxifylline (Option D), which increases microvascular perfusion by decreasing plasma cellular viscosity and cytokine inhibition, has been demonstrated to be a useful adjunct to compression by augmenting ulcer healing.</li><li>• The cause of a venous leg ulcer is venous hypertension and the keystone of management is to decrease this hypertension using venous ablation (Option B) and compression therapy.</li><li>• venous leg ulcer is venous hypertension and the keystone of management is to decrease this hypertension using venous ablation</li><li>• compression therapy.</li><li>• Pentoxifylline (Option D), which increases microvascular perfusion by decreasing plasma cellular viscosity and cytokine inhibition, has been demonstrated to be a useful adjunct to compression by augmenting ulcer healing.</li><li>• Pentoxifylline</li><li>• increases microvascular perfusion by decreasing plasma cellular viscosity and cytokine inhibition,</li><li>• Educational objective :</li><li>• Educational objective</li><li>• Superficial venous ablation or surgery : In patients with venous leg ulcers , treatment of superficial venous incompetence has been demonstrated to accelerate healing and reduce recurrence ; therefore, expeditious referral to a vascular service for assessment is recommended. Compression The most clinical and cost-effective compression regimes are two-layer compression hosiery or four-layer compression bandaging . The ideal interface pressure in pure venous ulceration is 35–40 mmHg. Skilled application of these dressings is essential for both safety and efficacy. Pentoxifylline , which increases microvascular perfusion by decreasing plasma cellular viscosity and cytokine inhibition , has been demonstrated to be a useful adjunct to compression by augmenting ulcer healing. Horse chestnut seed extract has been shown to be a safe and efficacious treatment for chronic venous hypertension , improving symptoms and reducing leg volume. A number of biological dressings have been developed, including fetal keratinocytes and collagen meshes, which have been shown to improve healing; however, they are not cost-effective for the majority of ulcers. Pinch grafts and ulcer excision with mesh grafting have been shown to provide good early healing with moderate long-term results (50% healed at 5 years).</li><li>• Superficial venous ablation or surgery : In patients with venous leg ulcers , treatment of superficial venous incompetence has been demonstrated to accelerate healing and reduce recurrence ; therefore, expeditious referral to a vascular service for assessment is recommended.</li><li>• Superficial venous ablation or surgery</li><li>• venous leg ulcers</li><li>• treatment of superficial venous incompetence</li><li>• accelerate healing and reduce recurrence</li><li>• Compression The most clinical and cost-effective compression regimes are two-layer compression hosiery or four-layer compression bandaging . The ideal interface pressure in pure venous ulceration is 35–40 mmHg. Skilled application of these dressings is essential for both safety and efficacy.</li><li>• Compression</li><li>• clinical and cost-effective compression regimes</li><li>• two-layer compression hosiery or four-layer compression bandaging</li><li>• Pentoxifylline , which increases microvascular perfusion by decreasing plasma cellular viscosity and cytokine inhibition , has been demonstrated to be a useful adjunct to compression by augmenting ulcer healing.</li><li>• Pentoxifylline</li><li>• increases microvascular perfusion</li><li>• decreasing plasma cellular viscosity</li><li>• cytokine inhibition</li><li>• Horse chestnut seed extract has been shown to be a safe and efficacious treatment for chronic venous hypertension , improving symptoms and reducing leg volume.</li><li>• Horse chestnut seed extract</li><li>• safe and efficacious treatment for chronic venous hypertension</li><li>• A number of biological dressings have been developed, including fetal keratinocytes and collagen meshes, which have been shown to improve healing; however, they are not cost-effective for the majority of ulcers.</li><li>• Pinch grafts and ulcer excision with mesh grafting have been shown to provide good early healing with moderate long-term results (50% healed at 5 years).</li><li>• Ref : Bailey and Love 28 th Ed. Pg 1040-41.</li><li>• Ref</li><li>• Bailey and Love 28 th Ed. Pg 1040-41.</li></ul>\n<p>@dams_new_robot</p>", "bot": "@dams_new_robot", "video": ""}]; if (!Array.isArray(questions) || questions.length === 0) { throw new Error("Questions data is empty or invalid"); } debugLog(`Successfully parsed ${questions.length} questions`); } catch (e) { console.error("Failed to parse questions_json:", e); document.getElementById('error-message').innerHTML = "Error loading quiz data. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('start-test').disabled = true; // Fallback to sample questions for testing questions = [ { text: "What is 2 + 2?", options: [ { label: "A", text: "3", correct: false }, { label: "B", text: "4", correct: true }, { label: "C", text: "5", correct: false }, { label: "D", text: "6", correct: false } ], correct_answer: "B. 4", question_images: [], explanation_images: [], explanation: "<p>2 + 2 = 4</p><p>@dams_new_robot</p>", bot: "@dams_new_robot", audio: "", video: "" } ]; debugLog("Loaded fallback questions"); } // Quiz state let currentQuestion = 0; let answers = new Array(questions.length).fill(null); let markedForReview = new Array(questions.length).fill(false); let timeRemaining = 73 * 60; // Duration in seconds let timerInterval = null; const quizId = `{title.replace(/\s+/g, '_').toLowerCase()}`; // Unique ID for local storage // Load saved progress function loadProgress() { try { debugLog("Loading progress from localStorage"); const saved = localStorage.getItem(`quiz_${quizId}`); if (saved) { const { savedAnswers, savedMarked, savedTime } = JSON.parse(saved); answers = savedAnswers || answers; markedForReview = savedMarked || markedForReview; timeRemaining = savedTime !== undefined ? savedTime : timeRemaining; debugLog("Progress loaded successfully"); } else { debugLog("No saved progress found"); } } catch (e) { console.error("Error loading progress:", e); debugLog("Failed to load progress: " + e.message); } } // Save progress function saveProgress() { try { debugLog("Saving progress to localStorage"); localStorage.setItem(`quiz_${quizId}`, JSON.stringify({ savedAnswers: answers, savedMarked: markedForReview, savedTime: timeRemaining })); debugLog("Progress saved successfully"); } catch (e) { console.error("Error saving progress:", e); debugLog("Failed to save progress: " + e.message); } } // Initialize quiz function initQuiz() { try { debugLog("Initializing quiz"); loadProgress(); const startButton = document.getElementById('start-test'); if (!startButton) { throw new Error("Start test button not found"); } startButton.addEventListener('click', startQuiz); debugLog("Start test button listener attached"); document.getElementById('previous-btn').addEventListener('click', showPreviousQuestion); document.getElementById('next-btn').addEventListener('click', showNextQuestion); document.getElementById('mark-review').addEventListener('click', toggleMarkForReview); document.getElementById('nav-toggle').addEventListener('click', toggleNavPanel); document.getElementById('submit-test').addEventListener('click', showSubmitModal); document.getElementById('continue-test').addEventListener('click', closeExitModal); document.getElementById('exit-test').addEventListener('click', () => { debugLog("Exiting test"); localStorage.removeItem(`quiz_${quizId}`); window.location.reload(); }); document.getElementById('cancel-submit').addEventListener('click', closeSubmitModal); document.getElementById('confirm-submit').addEventListener('click', submitTest); document.getElementById('take-again').addEventListener('click', () => { debugLog("Restarting test"); localStorage.removeItem(`quiz_${quizId}`); window.location.reload(); }); document.getElementById('review-test').addEventListener('click', () => showResults(currentResultQuestion)); document.getElementById('close-nav').addEventListener('click', toggleNavPanel); document.getElementById('theme-toggle').addEventListener('click', toggleTheme); document.getElementById('nav-filter').addEventListener('change', updateNavPanel); document.getElementById('prev-result').addEventListener('click', showPreviousResult); document.getElementById('next-result').addEventListener('click', showNextResult); document.getElementById('results-nav-toggle').addEventListener('click', toggleResultsNavPanel); document.getElementById('close-results-nav').addEventListener('click', toggleResultsNavPanel); document.getElementById('results-nav-filter').addEventListener('change', updateResultsNavPanel); debugLog("Quiz initialized successfully"); } catch (e) { console.error("Failed to initialize quiz:", e); debugLog("Failed to initialize quiz: " + e.message); document.getElementById('error-message').innerHTML = "Error initializing quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('start-test').disabled = true; } } // Start quiz function startQuiz() { try { debugLog("Starting quiz"); document.getElementById('instructions').classList.add('hidden'); document.getElementById('quiz').classList.remove('hidden'); showQuestion(currentQuestion); startTimer(); updateNavPanel(); debugLog("Quiz started successfully"); } catch (e) { console.error("Error starting quiz:", e); debugLog("Failed to start quiz: " + e.message); document.getElementById('error-message').innerHTML = "Error starting quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); document.getElementById('quiz').classList.add('hidden'); document.getElementById('instructions').classList.remove('hidden'); } } // Show question function showQuestion(index) { try { debugLog(`Showing question ${index + 1}`); currentQuestion = index; const q = questions[index]; if (!q) { throw new Error(`Question ${index} is undefined`); } document.getElementById('question-number').innerHTML = `Question <span>${index + 1}</span> of ${questions.length}`; document.getElementById('question-text').innerHTML = q.text || "No question text available"; const imagesDiv = document.getElementById('question-images'); imagesDiv.innerHTML = q.question_images && q.question_images.length > 0 ? q.question_images.map(url => `<img src="${url}" alt="Question Image" class="max-w-full h-auto rounded-lg">`).join('') : ''; const optionsDiv = document.getElementById('options'); optionsDiv.innerHTML = q.options && q.options.length > 0 ? q.options.map(opt => ` <button class="option-btn w-full text-left p-3 border rounded-lg ${answers[index] === opt.label ? 'selected' : ''}" onclick="selectOption(${index}, '${opt.label}')" aria-label="Option ${opt.label}: ${opt.text}"> ${opt.label}. ${opt.text} </button> `).join('') : '<p class="text-red-500">No options available</p>'; document.getElementById('previous-btn').disabled = index === 0; document.getElementById('next-btn').disabled = index === questions.length - 1; document.getElementById('mark-review').classList.toggle('marked', markedForReview[index]); updateProgressBar(); saveProgress(); window.scrollTo({ top: 0, behavior: 'smooth' }); debugLog(`Question ${index + 1} displayed successfully`); } catch (e) { console.error("Error displaying question:", e); debugLog("Failed to display question: " + e.message); } } // Select option function selectOption(index, label) { try { debugLog(`Selecting option ${label} for question ${index + 1}`); answers[index] = label; const optionsDiv = document.getElementById('options'); const optionButtons = optionsDiv.querySelectorAll('.option-btn'); optionButtons.forEach(btn => { const btnLabel = btn.textContent.trim().split('.')[0]; btn.classList.toggle('selected', btnLabel === label); }); updateNavPanel(); saveProgress(); debugLog(`Option ${label} selected for question ${index + 1}`); } catch (e) { console.error("Error selecting option:", e); debugLog("Failed to select option: " + e.message); } } // Toggle mark for review function toggleMarkForReview() { try { debugLog(`Toggling mark for review on question ${currentQuestion + 1}`); markedForReview[currentQuestion] = !markedForReview[currentQuestion]; document.getElementById('mark-review').classList.toggle('marked', markedForReview[currentQuestion]); updateNavPanel(); saveProgress(); debugLog(`Mark for review toggled for question ${currentQuestion + 1}`); } catch (e) { console.error("Error marking for review:", e); debugLog("Failed to mark for review: " + e.message); } } // Navigate to previous question function showPreviousQuestion() { try { debugLog(`Navigating to previous question from ${currentQuestion + 1}`); if (currentQuestion > 0) { currentQuestion--; showQuestion(currentQuestion); } } catch (e) { console.error("Error navigating to previous question:", e); debugLog("Failed to navigate to previous question: " + e.message); } } // Navigate to next question function showNextQuestion() { try { debugLog(`Navigating to next question from ${currentQuestion + 1}`); if (currentQuestion < questions.length - 1) { currentQuestion++; showQuestion(currentQuestion); } } catch (e) { console.error("Error navigating to next question:", e); debugLog("Failed to navigate to next question: " + e.message); } } // Handle question navigation click function handleQuestionNavClick(index) { try { debugLog(`Navigating to question ${index + 1} via nav panel`); showQuestion(index); toggleNavPanel(); } catch (e) { console.error("Error handling navigation click:", e); debugLog("Failed to navigate via nav panel: " + e.message); } } // Start timer function startTimer() { try { debugLog("Starting timer"); timerInterval = setInterval(() => { if (timeRemaining <= 0) { debugLog("Timer expired, submitting test"); clearInterval(timerInterval); submitTest(); } else { timeRemaining--; const minutes = Math.floor(timeRemaining / 60); const seconds = timeRemaining % 60; document.getElementById('timer').innerHTML = `Time Remaining: <span>${minutes.toString().padStart(2, '0')}:${seconds.toString().padStart(2, '0')}</span>`; saveProgress(); } }, 1000); debugLog("Timer started successfully"); } catch (e) { console.error("Error starting timer:", e); debugLog("Failed to start timer: " + e.message); } } // Update progress bar function updateProgressBar() { try { debugLog("Updating progress bar"); const progress = ((currentQuestion + 1) / questions.length) * 100; document.getElementById('progress-bar').style.width = `${progress}%`; debugLog("Progress bar updated"); } catch (e) { console.error("Error updating progress bar:", e); debugLog("Failed to update progress bar: " + e.message); } } // Update quiz navigation panel function updateNavPanel() { try { debugLog("Updating quiz navigation panel"); const filter = document.getElementById('nav-filter').value; const navGrid = document.getElementById('nav-grid'); navGrid.innerHTML = questions.map((_, i) => { if (filter === 'answered' && !answers[i]) return ''; if (filter === 'unanswered' && answers[i]) return ''; if (filter === 'marked' && !markedForReview[i]) return ''; return ` <button class="question-nav-btn ${answers[i] ? 'answered' : 'unanswered'} ${markedForReview[i] ? 'marked-nav' : ''}" onclick="handleQuestionNavClick(${i})" aria-label="Go to Question ${i + 1}"> ${i + 1} </button> `; }).join(''); debugLog("Quiz navigation panel updated"); } catch (e) { console.error("Error updating quiz navigation panel:", e); debugLog("Failed to update quiz navigation panel: " + e.message); } } // Update results navigation panel function updateResultsNavPanel() { try { debugLog("Updating results navigation panel"); const filter = document.getElementById('results-nav-filter').value; const navGrid = document.getElementById('results-nav-grid'); navGrid.innerHTML = questions.map((_, i) => { if (filter === 'answered' && !answers[i]) return ''; if (filter === 'unanswered' && answers[i]) return ''; if (filter === 'marked' && !markedForReview[i]) return ''; return ` <button class="result-nav-btn-grid ${answers[i] ? 'answered' : 'unanswered'} ${markedForReview[i] ? 'marked-nav' : ''}" onclick="handleResultNavClick(${i})" aria-label="Go to Result for Question ${i + 1}"> ${i + 1} </button> `; }).join(''); debugLog("Results navigation panel updated"); } catch (e) { console.error("Error updating results navigation panel:", e); debugLog("Failed to update results navigation panel: " + e.message); } } // Toggle quiz navigation panel function toggleNavPanel() { try { debugLog("Toggling quiz navigation panel"); const navPanel = document.getElementById('nav-panel'); navPanel.classList.toggle('hidden'); debugLog("Quiz navigation panel toggled"); } catch (e) { console.error("Error toggling quiz navigation panel:", e); debugLog("Failed to toggle quiz navigation panel: " + e.message); } } // Toggle results navigation panel function toggleResultsNavPanel() { try { debugLog("Toggling results navigation panel"); const resultsNavPanel = document.getElementById('results-nav-panel'); resultsNavPanel.classList.toggle('hidden'); if (!resultsNavPanel.classList.contains('hidden')) { updateResultsNavPanel(); } debugLog("Results navigation panel toggled"); } catch (e) { console.error("Error toggling results navigation panel:", e); debugLog("Failed to toggle results navigation panel: " + e.message); } } // Handle result navigation click function handleResultNavClick(index) { try { debugLog(`Navigating to result for question ${index + 1} via nav panel`); showResults(index); toggleResultsNavPanel(); } catch (e) { console.error("Error handling result navigation click:", e); debugLog("Failed to navigate to result: " + e.message); } } // Show submit modal function showSubmitModal() { try { debugLog("Showing submit modal"); const attempted = answers.filter(a => a !== null).length; document.getElementById('attempted-count').textContent = attempted; document.getElementById('unattempted-count').textContent = questions.length - attempted; document.getElementById('submit-modal').classList.remove('hidden'); debugLog("Submit modal displayed"); } catch (e) { console.error("Error showing submit modal:", e); debugLog("Failed to show submit modal: " + e.message); } } // Close submit modal function closeSubmitModal() { try { debugLog("Closing submit modal"); document.getElementById('submit-modal').classList.add('hidden'); debugLog("Submit modal closed"); } catch (e) { console.error("Error closing submit modal:", e); debugLog("Failed to close submit modal: " + e.message); } } // Close exit modal function closeExitModal() { try { debugLog("Closing exit modal"); document.getElementById('exit-modal').classList.add('hidden'); debugLog("Exit modal closed"); } catch (e) { console.error("Error closing exit modal:", e); debugLog("Failed to close exit modal: " + e.message); } } // Submit test function submitTest() { try { debugLog("Submitting test"); clearInterval(timerInterval); document.getElementById('quiz').classList.add('hidden'); document.getElementById('submit-modal').classList.add('hidden'); document.getElementById('results').classList.remove('hidden'); showResults(0); // Start with first question // Trigger confetti animation confetti({ particleCount: 100, spread: 70, origin: { y: 0.6 } }); localStorage.removeItem(`quiz_${quizId}`); debugLog("Test submitted successfully"); } catch (e) { console.error("Error submitting test:", e); debugLog("Failed to submit test: " + e.message); } } // Show result for a single question function showResults(index) { try { debugLog(`Showing result for question ${index + 1}`); currentResultQuestion = index; let correct = 0, wrong = 0, unanswered = 0, marked = 0; answers.forEach((answer, i) => { const isCorrect = answer && questions[i].options.find(opt => opt.label === answer)?.correct; if (answer === null) unanswered++; else if (isCorrect) correct++; else wrong++; if (markedForReview[i]) marked++; }); const q = questions[index]; if (!q) { throw new Error(`Question ${index} is undefined`); } const userAnswer = answers[index]; const isCorrect = userAnswer && q.options.find(opt => opt.label === userAnswer)?.correct; const resultsContent = document.getElementById('results-content'); resultsContent.innerHTML = ` <div class="border p-4 rounded-lg ${isCorrect ? 'bg-green-50' : userAnswer ? 'bg-red-50' : 'bg-gray-50'}"> <p class="font-semibold">Question ${index + 1}: ${q.text || 'No question text'}</p> ${q.question_images && q.question_images.length > 0 ? q.question_images.map(url => `<img src="${url}" alt="Question Image" class="max-w-full h-auto rounded-lg my-2">`).join('') : ''} <p><strong>Your Answer:</strong> ${userAnswer ? `${userAnswer}. ${q.options.find(opt => opt.label === userAnswer)?.text || 'Invalid option'}` : 'Unanswered'}</p> <p><strong>Correct Answer:</strong> ${q.correct_answer || 'Unknown'}</p> <div class="mt-2">${q.explanation || 'No explanation available'}</div> ${q.explanation_images && q.explanation_images.length > 0 ? q.explanation_images.map(url => `<img src="${url}" alt="Explanation Image" class="max-w-full h-auto rounded-lg my-2">`).join('') : ''} ${q.video ? ` <button class="play-video bg-blue-500 text-white px-4 py-2 rounded-lg mt-2" onclick="loadVideo(this, '${q.video}', 'video-${index}')" aria-label="Play explanation video for Question ${index + 1}"> Play Video Explanation </button> <div id="video-${index}" class="video-container mt-2"></div> ` : '<p class="text-gray-500 mt-2">No video available</p>'} ${q.audio ? ` <button class="play-audio bg-blue-500 text-white px-4 py-2 rounded-lg mt-2" onclick="loadAudio(this, '${q.audio}', 'audio-${index}')" aria-label="Play audio explanation for Question ${index + 1}"> Play Audio Explanation </button> <div id="audio-${index}" class="audio-container mt-2"></div> ` : ''} </div> `; document.getElementById('correct-count').textContent = correct; document.getElementById('wrong-count').textContent = wrong; document.getElementById('unanswered-count').textContent = unanswered; document.getElementById('marked-count').textContent = marked; document.getElementById('result-question-number').innerHTML = `Question <span>${index + 1}</span> of ${questions.length}`; document.getElementById('prev-result').disabled = index === 0; document.getElementById('next-result').disabled = index === questions.length - 1; updateResultsNavPanel(); window.scrollTo({ top: 0, behavior: 'smooth' }); debugLog(`Result for question ${index + 1} displayed successfully`); } catch (e) { console.error("Error displaying result:", e); debugLog("Failed to display result: " + e.message); } } // Navigate to previous result function showPreviousResult() { try { debugLog(`Navigating to previous result from question ${currentResultQuestion + 1}`); if (currentResultQuestion > 0) { showResults(currentResultQuestion - 1); } } catch (e) { console.error("Error navigating to previous result:", e); debugLog("Failed to navigate to previous result: " + e.message); } } // Navigate to next result function showNextResult() { try { debugLog(`Navigating to next result from question ${currentResultQuestion + 1}`); if (currentResultQuestion < questions.length - 1) { showResults(currentResultQuestion + 1); } } catch (e) { console.error("Error navigating to next result:", e); debugLog("Failed to navigate to next result: " + e.message); } } // Lazy-load video function loadVideo(button, videoUrl, containerId) { try { debugLog(`Loading video for ${containerId}: ${videoUrl}`); if (!videoUrl) { const container = document.getElementById(containerId); container.innerHTML = `<p class="text-gray-500">No video available</p>`; button.remove(); debugLog("No video URL provided"); return; } const container = document.getElementById(containerId); container.innerHTML = ` <div class="video-loading"></div> <video controls class="w-full max-w-[600px] rounded-lg" preload="metadata" aria-label="Video explanation"> <source src="${videoUrl}" type="${videoUrl.endsWith('.m3u8') ? 'application/x-mpegURL' : 'video/mp4'}"> Your browser does not support the video tag. </video> `; container.classList.add('active'); button.remove(); // Initialize HLS.js for .m3u8 videos const video = container.querySelector('video'); if (videoUrl.endsWith('.m3u8') && Hls.isSupported()) { const hls = new Hls(); hls.loadSource(videoUrl); hls.attachMedia(video); hls.on(Hls.Events.ERROR, (event, data) => { console.error("HLS.js error:", data); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; debugLog("HLS.js error: " + JSON.stringify(data)); }); } else if (videoUrl.endsWith('.m3u8') && video.canPlayType('application/vnd.apple.mpegurl')) { video.src = videoUrl; } // Handle video load errors video.onerror = () => { console.error("Video load error for URL:", videoUrl); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; debugLog("Video load error for URL: " + videoUrl); }; // Remove loading spinner when video is ready video.onloadedmetadata = () => { container.querySelector('.video-loading').remove(); debugLog("Video loaded successfully"); }; } catch (e) { console.error("Error loading video:", e); debugLog("Failed to load video: " + e.message); const container = document.getElementById(containerId); container.innerHTML = `<p class="text-red-500">Error loading video. <a href="${videoUrl}" target="_blank" aria-label="Open video in new tab">Open video</a></p>`; } } // Lazy-load audio function loadAudio(button, audioUrl, containerId) { try { debugLog(`Loading audio for ${containerId}: ${audioUrl}`); if (!audioUrl) { const container = document.getElementById(containerId); container.innerHTML = `<p class="text-gray-500">No audio available</p>`; button.remove(); debugLog("No audio URL provided"); return; } const container = document.getElementById(containerId); container.innerHTML = ` <audio controls class="w-full max-w-[600px]" preload="metadata" aria-label="Audio explanation"> <source src="${audioUrl}" type="audio/mpeg"> Your browser does not support the audio tag. </audio> `; container.classList.add('active'); button.remove(); // Handle audio load errors const audio = container.querySelector('audio'); audio.onerror = () => { console.error("Audio load error for URL:", audioUrl); container.innerHTML = `<p class="text-red-500">Error loading audio. <a href="${audioUrl}" target="_blank" aria-label="Open audio in new tab">Open audio</a></p>`; debugLog("Audio load error for URL: " + audioUrl); }; debugLog("Audio loaded successfully"); } catch (e) { console.error("Error loading audio:", e); debugLog("Failed to load audio: " + e.message); const container = document.getElementById(containerId); container.innerHTML = `<p class="text-red-500">Error loading audio. <a href="${audioUrl}" target="_blank" aria-label="Open audio in new tab">Open audio</a></p>`; } } // Toggle dark mode function toggleTheme() { try { debugLog("Toggling theme"); document.documentElement.classList.toggle('dark'); localStorage.setItem('theme', document.documentElement.classList.contains('dark') ? 'dark' : 'light'); debugLog("Theme toggled successfully"); } catch (e) { console.error("Error toggling theme:", e); debugLog("Failed to toggle theme: " + e.message); } } // Load theme preference function loadTheme() { try { debugLog("Loading theme preference"); const theme = localStorage.getItem('theme'); if (theme === 'dark') { document.documentElement.classList.add('dark'); } debugLog("Theme loaded successfully"); } catch (e) { console.error("Error loading theme:", e); debugLog("Failed to load theme: " + e.message); } } // Initialize on DOM content loaded window.addEventListener('DOMContentLoaded', () => { try { debugLog("DOM content loaded, initializing quiz"); loadTheme(); initQuiz(); } catch (e) { console.error("Error during DOMContentLoaded:", e); debugLog("Failed to initialize on DOMContentLoaded: " + e.message); document.getElementById('error-message').innerHTML = "Error initializing quiz. Please check the console for details or contact support."; document.getElementById('error-message').classList.remove('hidden'); } }); </script> </body> </html>" frameborder="0" width="100%" height="2000px">